International Journal of Cardiology xxx (2014) xxx–xxx

IJCA-18493; No of Pages 3

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International Journal of Cardiology

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Letters to the Editor

Mitral valve repair is an effective treatment for ventricular arrhythmias inmitral valve prolapse syndrome

Deepika R. Abbadi a,⁎, Rahul Purbey d, Indu G. Poornima b,c

a Internal Medicine, Allegheny General Hospital, 320 E North Avenue, Pittsburgh, PA 15212, United Statesb Nuclear Cardiology, Allegheny General Hospital, United Statesc Cardiology Fellowship, Allegheny General Hospital, United Statesd Allegheny General Hospital, United States

⁎ Corresponding author. Tel.: +1 4129994816 (Cell), +E-mail address: dabbadi@wpahs.org (D.R. Abbadi).

http://dx.doi.org/10.1016/j.ijcard.2014.07.1740167-5273/Published by Elsevier Ireland Ltd.

Please cite this article as: Abbadi DR, et al,syndrome, Int J Cardiol (2014), http://dx.doi

a r t i c l e i n f o

Article history:

Received 7 June 2014Accepted 27 July 2014Available online xxxx

Keywords:Mitral valve prolapseMitral valve prolapse syndromeVentricular arrhythmiasSudden cardiac deathMitral regurgitation

Transesophageal echocardiogram showed bi-leaflet MVP, moderate toseveremitral regurgitation (See Fig. 2.), dilatedmitral annulus, thick re-dundantmitral leaflets, torn secondary chordae tendineae to the anteri-or mitral leaflet and normal left ventricular end-diastolic and end-systolic diameter with left ventricular ejection fraction of 55–60%. Coro-nary angiography to exclude spontaneous coronary dissection showednormal coronaries. Cardiac MRI did not reveal arrhythmogenic rightventricular dysplasia or hypertrophic cardiomyopathy but revealedsome patchy fibrosis in the anteroseptal and posterior walls. A defibril-lator was implanted for recurrent runs of VT. She was discharged homeon aspirin and metoprolol.

The prognosis of ventricular arrhythmias associated with mitralvalve prolapse (MVP) syndrome is unclear. We present a case of MVPthat emphasizes the role of mitral valve repair in the treatment of ven-tricular arrhythmias resulting from this condition. The case also illus-trates the need for high vigilance in those with malignant features ofMVP, to prevent sudden cardiac death.

A 36-year-old Caucasian female with history of a benign murmursince adolescence, complained of sudden onset palpitations and dizzi-ness in her 4th postpartum month and suffered a cardiac arrest. Herpregnancy and delivery were uneventful except for mild pregnancy in-duced hypertension that resolved after delivery. Since delivery, she hadthree episodes of near syncope and an echocardiogram showed bileafletMVP with moderate mitral regurgitation and normal left ventricularsystolic function. A 24-hour Holter monitor performed 2 weeks beforepresentation demonstrated frequent PVC's and she was started onmet-oprolol 25 mg twice daily. After successful resuscitation from ventricu-lar fibrillation, physical examination revealed a holosystolic murmur inthe apical area without evidence of congestive heart failure. EKGshowed sinus tachycardia with frequent premature ventricular contrac-tions (PVC) in bigeminy and short runs of nonsustained ventriculartachycardia (NSVT). QTc and cardiac enzymes were normal. Intrave-nous amiodarone was initiated but due to persistent, recurrent runs of

1 4123594970 (Office).

Mitral valve repair is an effe.org/10.1016/j.ijcard.2014.07.

NSVT, lidocaine was added with decrease in frequency of arrhythmias.

Persistent symptoms continued with palpitations, near syncope andfatigue. Interrogation of her defibrillator showed multiple PVC's withruns of NSVT unresponsive to higher doses of metoprolol. The frequencyof PVC's decreased after initiation of Dilantin 400 mg three times daily.This decreased her ectopic burden but she continued to be symptomaticwith palpitations. Although she did not have any symptoms of volumeoverload and left ventricular dimensions did not meet surgical criteriafor mitral valve repair, she was referred for mitral valve repair due tothe persistent arrhythmias and symptoms. She underwent mitral valverepair with a #36 Edwards Physio Annuloplasty ringwith no residual mi-tral regurgitation on the postoperative echo. No episodes of NSVT werenoted in the postoperative period. After discharge, Dilantin has been ta-pered off and discontinued and the dose of metoprolol has been progres-sively decreased. Three years postoperatively, no ICD shocks have beenreported and the patient does not report any palpitations.

Mitral valve prolapse usually has a benign course, but can occasion-ally lead to serious complications [1]. Someof themare due to autonom-ic dysfunction causing malignant arrhythmias, syncope, pre-syncope,orthostatic hypotension and sudden cardiac death [2]. Bi-leaflet MVP,female gender, biphasic or inverted T waves in the inferior leads, andfrequent complex ventricular ectopic activity including PVC's of the out-flow tract alternating with PVCs of papillary or fascicular origin, as seenin our patient (See Fig. 1.), were collectively described as a ‘malignant’phenotype ofMVP by Sriram et al. [3]. However this retrospective seriesdid not examine the role ofmitral valve surgery on the incidence of ven-tricular arrhythmias in survivors of cardiac arrest.

The estimated rate of SCD in patients with MVP is 16–40 per 10,000(0.2–0.4%) per year and twice the incidence in the general population[5]. Univariable predictors of ventricular arrhythmias include

ctive treatment for ventricular arrhythmias in mitral valve prolapse174

Fig. 1. EKG rhythm strips showing multiple PVC's and NSVT.

e2 D.R. Abbadi et al. / International Journal of Cardiology xxx (2014) xxx–xxx

echocardiographically-determined isovolumetric relaxation time, LVdi-latation and dysfunction, mitral anterior leaflet length [4], thickness ofthe redundant leaflet [1,5], chordal rupture causing flail mitral leafletand the presence of moderate to severe mitral regurgitation [1,6].

Fig. 2. ECHO with color doppler show

Please cite this article as: Abbadi DR, et al, Mitral valve repair is an effesyndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.

Ackay et al. identified anteriormitral leaflet length alongwith enhancedQTc dispersion as independent predictors of VT in patients with classicMVP of N5 mm, as observed in our patient [1,6]. Gornick et al. showedthat papillary muscle traction in a canine heart model could lead to

ing severe mitral regurgitation.

ctive treatment for ventricular arrhythmias in mitral valve prolapse174

e3D.R. Abbadi et al. / International Journal of Cardiology xxx (2014) xxx–xxx

significant regional changes in ventricular refractoriness [7] and a simi-lar mechanism could be operational in humans. Delayed contrast en-hancement of the papillary muscles on cardiac MRI could representfibrosis of papillary muscles and a nidus for arrhythmias [8]. Guidelinesfor surgical repair ofmitral valve prolapse typically include symptoms ofvolume overload and left ventricular dilatation in the presence of severemitral regurgitation and MVP [9,10]. More recent studies advocate forearly surgical intervention especially when repair is feasible, even inasymptomatic patients [9,10]. However ventricular arrhythmias aretypically not a consideration for surgical intervention as there is not aclear association between the severity of mitral regurgitation and ar-rhythmias. In our patient with a malignant phenotype of MVP, surgicalintervention clearly reduced the incidence of ventricular arrhythmias.Future studies need to evaluate the value of early surgical interventionin patients with a similar phenotype.

Conflict of interest

The authors report no relationships that could be construed as a con-flict of interest.

Please cite this article as: Abbadi DR, et al, Mitral valve repair is an effesyndrome, Int J Cardiol (2014), http://dx.doi.org/10.1016/j.ijcard.2014.07.

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