Download Slide 1

Mitral Valve Prolapse and
Regurgitation
Jason Infeld, MD, FACC
Stern Cardiovascular
Foundation
DISCLOSURE
Jason Infeld
MD, FACC
Stern Cardiovascular Foundation
I have the following personal financial relationships
with commercial interests to disclose:
NONE
Mitral Valve Prolapse (MVP)
•
•
•
•
MVP is the most common cause of mitral
regurgitation and of congenital valvular heart
disease in adults
Definition and diagnostic criteria have
changed leading to significant controversy
Many common perceptions about this
disease have been recently been shown to be
false
Disease was widely overdiagnosed in the 70’s
and 80’s as echocardiography became more
widely available
What is MVP?
•
•
Systolic bowing of one or both mitral
valve leaflets across the plane of the
mitral valve annulus into the LA
Disease is often benign, but may be
associated severe complications
including mitral regurgitation,
endocarditis, and arrythmias.
Classic Mitral-Valve Prolapse during Systole
Freed L et al. N Engl J Med 1999;341:1-7
Classic Mitral-Valve Prolapse with Leaflet Thickening (Arrows)
during Diastole
Freed L et al. N Engl J Med 1999;341:1-7
How common is MVP?
•
•
•
Early prevalence estimates between 5
and 20% and up to 35% in some studies
Disease was thought to be more
common in young women
Studies were faulty due to severe
selection bias and a lack of clear
echocardiographic criteria
History of MVP
•
•
•
•
Described accurately in the 60’s by
Barlow in a group of patients with
midsystolic clicks and mitral
regurgitation seen during cardiac
catheterization. Diagnosis was rare.
1970 – first description of M-mode
echocardiographic findings.
Echo led to sudden dramatic increase in
the diagnosis of this entity
Early studies shows prevalence as high
as 35%
History of MVP
•
•
•
1980’s widespread use of 2dimensional echo
Use of apical 4-chamber view
continued to lead to significant
overdiagnosis
1987 – study published demonstrating
the normal shape of the mitral valve as
a “saddle” and that the 4-chamber
view should not be used to make the
diagnosis
Prevalence
•
•
•
•
•
•
Framingham study - prevalence
approximately 1.1%
Reviewed echos of 3591 men and women
5 to 1 ratio of self-reported diagnosis of MVP
and echocardiographic MVP
Prevalence equal between men and women
MVP patients were thinner and had more
MR
Average amount of MR was trace to mild
Echocardiography
Apical 4-chamber view
Parasternal Long-axis View

Leaflet displacement


Greater than 2mm
above the plane of the
mitral annulus in the
parasternal long-axis
view
Leaflet thickening

Greater than 5mm in the
midportion of the
anterior mitral leaflet
Echocardiography
•
•
•
•
Classical vs. nonclassic MVP
>2mm displacement and >5mm
thickness are considered to have classic
MVP
Patients with leaflet thickeness <5mm
have nonclassic MVP
Symmetric vs Asymmetric prolapse
Diagnostic Pitfalls
•
Non-specific echo findings
•
M-mode
•
Apical 4-chamber view
•
•
Physical exam. Midsystolic clicks are
common in normal individuals.
Symptoms: non-specific with significant
overlap with other disease processes
Natural History of MVP
•
•
•
•
MVP is generally benign, but serious
complications do occur
Complications of MVP are infective
endocarditis, cerebrovascular accidents,
atrial fibrillation, the need for mitral valve
surgery, and death
Complication rates are between 1 and 4%
annually
Complication rates vary amongst studies due
to referral bias of the most serious cases to
tertiary centers and maybe lower than
reported
Complications
•
Primary risk factors(RFs) for
complications
–
Moderate to severe MR
–
EF less than 50%
Complications
•
Secondary risk factors
–
Slight MR
–
Left atrial dimension > 40 mm
–
Flail leaflet
–
Atrial fibrillation (AF)
–
Age >50 years.
2006 ACC/AHA Guidelines
•
•
•
Repeat echocardiography at yearly intervals
in patients with high-risk findings on the
initial echocardiogram (eg, diffuse thickening
of the mitral leaflets and redundancy), or
moderate MR.
Clinical evaluation and repeat
echocardiography every 6 to 12 months in
patients with severe MR
Clinical evaluation and echocardiography at
any time there is a change in signs of
symptoms.
Treatment of MVP
Endocarditis Prophylaxis
•
•
•
The 2007 American Heart Association (AHA)
guideline for the prevention of infective
endocarditis made major revisions to the
1997 AHA guideline.
MVP with mitral regurgitation is no longer
considered a high risk valve lesion and
prophylaxis is no longer recommended.
Although MVP is associated with an
increased risk of endocarditis, there are no
convincing data that antibiotic prophylaxis is
effective in preventing episodes of
endocarditis
Treatment and F/u of MR
4/4/13
4/4/13
Chronic Mitral Regurgitation
•
Most patients asymptomatic even with severe
MR
•
Progressive dilatation of the LA and LV.
•
LA enlargement may result in atrial fibrillation
•
•
•
•
Moderate to severe MR may eventually result in
LV dysfunction and development of CHF
Pulmonary hypertension may occur with
associated right ventricular dysfunction.
Typically prolonged asymptomatic interval
Maybe an accelerated phase as a result of
ruptured mitral valve chordae leading to
progressive left atrial and LV dysfunction and
atrial fibrillation
Goals of Treatment
•
•
•
Prevent irreversible LV dysfunction,
pulmonary HTN, or atrial fibrillation in
an asymptomatic patient
Relieve symptoms of dyspnea and
fatigue in symptomatic patients
Prevent sudden cardiac death
Mitral Valve Repair vs
Replacement
Mitral Valve Repair
•
•
•
•
Ideal treatment for mitral regurgitation.
Avoids need for anticoagulation and
long-term risks of valve prosthesis
Preserves mitral valve anatomy leading
to better post-operative LV function
and survival
Repair is surgeon specific and success is
highly correlated with volume
Mitral Valve Repair
•
•
•
•
Clinician needs to be able to determine the
likelihood of repair
Isolated posterior leaflet prolapse more
amenable to repair
Presence of severe anterior leaflet prolapse,
severe valve thickening and calcification
make repair less likely
TEE is recommended pre-operatively to
define pathology and mechanism of MR
How is it done?
The Robot
Flail Mitral Leaflet
•
•
•
Subset of patients who do clinically
worse even in the absence of
progressive LV dilatation or
dysfunction.
Higher-risk of sudden cardiac death
Referral for early surgical treatment if
valve amenable to repair.
Flail Mitral Leaflet
TEE
•
•
Plays an important role in the
evaluation of MR due to the proximity
of the TEE probe to the LA
TTE can underestimate MR due to
shadowing from calcification and
prosthetic valves
•
Defines mechanism and severity of MR
•
Ideal test to assess if repair is feasible
4/4/13
4/4/13
4/4/13
Questions?