Mitral valve prolapse

Mitral valve prolapse K SRINIVAS, GEN MEDSYNONYMSSYSTOLIC CLICK MURMUR SYNDROMEBARLOW SYNDROMEBILLOWING MITRAL CUSP SYNDROMEFLOPPY VALVE SYNDROMEREDUNDANT CUSP SYNDROMEMYXOMATOUS MITRAL VALVE SYNDROME

2/1/20152MITRAL VALVE PROLAPSEANATOMY2/1/2015MITRAL VALVE PROLAPSE3

2/1/2015MITRAL VALVE PROLAPSE4

CLASSIFICATIONMVP SYNDROMEyounger age, predominantly femaleClick or click murmur on phy examThin leaflets with systolic displacement on echoLow BP, palpitations, orthostatic hypotension.Benign long term course2/1/20155MITRAL VALVE PROLAPSE MYXOMATOUS MITRAL VALVE DISEASEOlder age, predominantly male.Thickened redundant valve leaflets.MR on phy exam and echoProgressive disease requiring mitral valve surgery.2/1/20156MITRAL VALVE PROLAPSESECONDARY MVPMarfans syndrome.Hypertrophic cardiomyopathy.Ehlers danlos syndromeOther connective tissue disorders.2/1/20157MITRAL VALVE PROLAPSEPATHOLOGYMyxomatous proliferation of the leaflets.Quantity of acid mucopolysacchaide is increased.Fibrosis of the surface mitral valve leaflets.Thinning and elongation of chordae tendineae and ventricular friction lesions.2/1/20158MITRAL VALVE PROLAPSE2/1/2015MITRAL VALVE PROLAPSE9

2/1/2015MITRAL VALVE PROLAPSE10

MVP AND MR Degeneration of collagen and myxomatous changes of the chordae tendineae

Decrease in tensile strength.

Chordal rupture

Severity of MR2/1/201511MITRAL VALVE PROLAPSE Myxomatous changes in the annulus

Anuular dilatation and calcification

MR 2/1/201512MITRAL VALVE PROLAPSE2/1/2015MITRAL VALVE PROLAPSE13

CLINICAL PRESENTATIONAll ages and both sexes.Vast majority of ptnts are asymptomatic.SyncopePresyncopepalpitations 2/1/201514MITRAL VALVE PROLAPSE142/1/2015MITRAL VALVE PROLAPSE15chest discomfortSymptoms of dimnished cardiac output.Symptomatic arrhythmias.

PHYSICAL EXAMINATION2/1/2015MITRAL VALVE PROLAPSE16Body wt is often low.BP is low or normal.Orthostatic hypotension may be present.Higher prevalence of straight back syndrome, scoliosis and pectus exacavatum.AUSCULTATION2/1/2015MITRAL VALVE PROLAPSE17Non ejection systolic click at least 0.14 sec after S1. Multiple mid or late systolic click are audible along the lower sternal border due to sudden tensing of the elongated chordae tendinieae and prolapsed leaflets 2/1/2015MITRAL VALVE PROLAPSE18Often followed by a Mid to late crescendo systolic murmur that continues to A2.Duration of murmur is function of severity of MR.Commences earlier in severe MR.Confined to later portion in mild MR.

2/1/2015MITRAL VALVE PROLAPSE19Click and murmurBoth Only clickOnly murmrurboth are absent

DYNAMIC AUSCULTATION2/1/2015MITRAL VALVE PROLAPSE20The mitral valve begins to prolapse, when the reduction of LV volume during systole reaches a critical point at which the valve leaflets can no longer coapt, at that instant click occurs and murmur follows.2/1/2015MITRAL VALVE PROLAPSE21Any maneuver that decreases LV volume results in earlier occurrence of prolapse, click and murmur moves close towards S1 and vice versa

2/1/2015MITRAL VALVE PROLAPSE22

Straining phase of valsalva maneuver.Sudden standing.SquattingLeg raisingStanding to supine position.Isometric exercises2/1/201523MITRAL VALVE PROLAPSELV volume LV volume Straining phase of valsalva maneuverMurmur increases in durationAfter a premature beatRemains unchanged or decreasesMurmur increases in intensity.

Increases in intensity and duration2/1/201524MITRAL VALVE PROLAPSEMVPHCMDIFF B/W HCM AND MVPECHOCARDIOGRAPHY2/1/2015MITRAL VALVE PROLAPSE25Essential role in diagnosis of MVP.One or both mitral leaflets must billow by atleast 2mm in to the right atrium during systole. Thickening of the involved leaflet to more than 5mm supports the diagnosis.2/1/2015MITRAL VALVE PROLAPSE26

2/1/2015MITRAL VALVE PROLAPSE27Severe myxomatous disease include increased leaflet area, leaflet redundancy, chordal elongation and annular dilatation. TEE provides additional details regarding the integrity of mitral valve apparatus

2/1/2015MITRAL VALVE PROLAPSE28

ECG2/1/2015MITRAL VALVE PROLAPSE29Normal in many asymptomatic patients.In some, inverted or biphasic T waves and nonspecific ST segment changes in inferior leads.

2/1/2015MITRAL VALVE PROLAPSE30ARRHYTHMIASAtrial and ventricular premature contractionsSupraventricular and ventricular tachyarrhythmias and bradyarrhythmias caused by sinus node dysfunction and AV block.

2/1/2015MITRAL VALVE PROLAPSE31Diastolic depolarization of muscle fibres in the ant mitral leaflets in response to stretch2/1/2015MITRAL VALVE PROLAPSE32ANGIOGRAPHYRight anterior oblique projection -post leafletLeft anterior oblique projection - ant leafletReveals scalloped edges of the leaflets determing the redundancy of tissueDISEASE COURSE2/1/2015MITRAL VALVE PROLAPSE33PRIMARY RISK FACTORSModerate to severe MRLV ejection fraction less than 50%.SECONDARYMild MRLeft atrial dimension more than 40mmFlial leafletAge >50

2/1/2015MITRAL VALVE PROLAPSE34

2/1/2015MITRAL VALVE PROLAPSE35

COMPLICATIONS2/1/2015MITRAL VALVE PROLAPSE36Progressive MRAFPulmonary hypertensionHeart failure2/1/2015MITRAL VALVE PROLAPSE37EndocarditisAcute hemiplegiaTIACerebellar infarcts.

MVP AND SUDDEN DEATH2/1/2015MITRAL VALVE PROLAPSE38Risk is twice the normal.Probably bcoz of increased ventricular arrhythmias.Risk is increased with severity of MR QT interval prolongation H/O syncope and palpitations MANAGEMENT2/1/2015MITRAL VALVE PROLAPSE39Asymptomatic patients with no arrhythmias and evidence of MR have good prognosis.Follow up for every3-5 years with echo and flow doppler study.

2/1/2015MITRAL VALVE PROLAPSE40Patients with long systolic murmur should be evaluated more frequently ever 12 months Endocardial prophylaxis is no longer recommended.2/1/2015MITRAL VALVE PROLAPSE41Patients with history of syncope, palpitations dizziness or lightheadedness , ventricular arrhythmias or QT prolongation on ecg should undergo 24 hours ambulatory monitoring to detect arrhythmias.

2/1/2015MITRAL VALVE PROLAPSE42Beta adrenergic blocking agentsFor palpitations secondary to premature ventricular contractions and self terminating SVT.Radiofrequency ablation for prolonged SVTFor chest discomfort

2/1/2015MITRAL VALVE PROLAPSE43AspirinFor patients with MVP who had a focal neurological event with out evidence left atrial thrombus or AF. 2/1/2015MITRAL VALVE PROLAPSE44Patients with MVP and severe MR may require mitral valve surgery.Mitral valve repair with out replacement is possible over 90%2/1/2015MITRAL VALVE PROLAPSE45SURGERYResection of the most deformed leaflet segment, most often the middle scallop of the post leaflet and insertion of an annuloplasty ring.

2/1/2015MITRAL VALVE PROLAPSE46Repair of the ant leaflet is more challenging, rupture of chordae tendineae can some times be treated by chordal transfer from the post leaflet.2/1/2015MITRAL VALVE PROLAPSE47