Mitral Valve Prolapse

Mitral Valve Prolapse

Workshop 12Group 3Section D

MM 23 y/o Chief complaint : PalpitationsHistory of Present Illness:

4 years PTA

•Palpitations ( irregular), heartbeats associated with increased sweating and shortness of breath.

•Medication: verapamil for 3 days, taken intermittently for palpitation

Few hours PTA •Palpitation accompanied by shortness of

breath

Review of Systems

No dizziness, nor loss of consciousness

No cough or colds No PND or orthopnea

Physical Examination

Conscious, coherent, ambulatory BP 110/70 CR 80/min regular RR

16/min BMI 19 Symmetrical chest expansion, narrow AP

diameter of the chest, no retractions, clear breath sounds

Adynamic precordium, AB at 5th LICS MCL no murmurs, (+) midsystolic click follwed by 2/6 mid-systolic crescendo murmur noted at the apex

Laboratory and Ancillary Tests 2D Echo-doppler:

Mitral Valve Prolapse, Anterior Mitral Valve Leaflet with moderate MR

Slightly dilated left atrium woth no evidence of thrombus

12 Lead ECG Sinus rhythm Occasional premature atrial complexes

1. What are the common physical examination findings of MVP?

Common PE findings of MVP

Auscultation Mid – late (non- ejection)

systolic click (0.14s) after S1 Systolic clicks: multiple and

may be follwed by a high-pitched, late systolic crescendo-decrescendo murmur, “ whooping” or “honking”- heard best at apex

Early click-murmur▪ Standing, during valsalva

maneuver, and with ant intervention that decreases LV volume

Delayed and complex click-murmur▪ Squatting, isometric exercises

which increase LV volume

Laboratory Examination

ECG- normal but may show biphasic or

inverted T waves in leads II, III and aVF,

and occasionally supraventricular or

ventricular premature beats

2DEcho – systolic dysplacement (in the parasternal long axis

view) of the mitral valve leaflets by at

least 2mm into the LA superior to the plane of the mitral annulus

Color flow – helpful in revealing associated

MR

2. What are the common and uncommon symptoms of MVP?

Population group

14 - 30 years old Women Increased familial incidence

Reference: Fauci et al. Harrison’s Principles of Internal Medicine, 17th ed.

Common Symptoms * Patients are mostly asymptomatic Others may manifest with: Easy fatigability Shortness of breath Palpitation Non-anginal chest pain Light-headedness Syncope


Uncommon Symptoms Transient ischemic attacks Congestive cardiac failure Endocarditis

in MR associated with MVP Sudden death


Symptoms related to autonomic dysfunction are usually associated with genetic inheritance:

Anxiety Panic attacks Arrhythmias Exercise intolerance Palpitations Atypical chest pain Fatigue Orthostasis Syncope or presyncope Neuropsychiatric symptoms

Thakkar, B. (2008) Mitral Valve Prolapse < http://emedicine.medscape.com/article>

Symptoms related to progression of mitral regurgitation :

Fatigue Dyspnea Exercise intolerance Orthopnea Paroxysmal nocturnal dyspnea (PND) Progressive signs of congestive heart

failure (CHF)

Thakkar, B. (2008) Mitral Valve Prolapse < http://emedicine.medscape.com/article>

3. What are the long-term complications of MVP?

In most studies, MVP has a complication rate of less than 2 percent per year2,15 .

The age-adjusted survival rate in men and women with MVP is similar to that in patients without this common clinical disorder

Complications of Mitral Valve Prolapse

Atrial fibrillation and other arrhythmiasCongestive heart failurePulmonary hypertensionRuptured mitral valve chordaeInfective endocarditisCentral nervous system embolic

events

O'Rourke RA. The mitral valve prolapse syndrome. In: Chizner MA, ed. Classic teachings in clinical cardiology. Cedar Grove, N.J.: Laennec, 1996:1049-70.

Congestive Heart FailureGradual progression of mitral

regurgitation

progressive dilation of the left atrium and left ventricle

atrial fibrillation, moderate to severe mitral regurgitation

LV dysfunction

congestive heart failure

Infective Endocarditis A serious complication of

MVP MVP is the leading

predisposing cardiovascular disorder in patients with endocarditis.

Because the absolute incidence of endocarditis is extremely low in the entire MVP population, the risk of its developing in these patients has been a subject of considerable debate.

Thromboembolic Events Rarely, fibrin emboli may cause visual problems

related to occlusion of the ophthalmic or posterior cerebral circulation.

Patients younger than 45 years who have MVP are at greater risk for cerebrovascular accidents than would be expected in similar patients without MVP.

Therefore, it has been recommended that antiplatelet drugs such as aspirin or anticoagulants be administered to patients with MVP who have a history of suspected cerebral emboli

4. What population group is associated with an increased predilection for MVP?

Idiopathic MVP

Cause of MVP may be a genetically determined collagen disorder

Electron microscopy: fragmentation of collagen fibrils

Reduction in the production of type III

collagen

Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17th ed.Venugopalan. 2008. Mitral Valve Prolapse.

<http://emedicine.medscape.com/article/890425-overview>

Hereditary Connective Tissue Disorders

Mitral valve prolapse is a frequent finding in patients of this population

Ehler-Danlos

syndrome

Marfan syndrome

Osteogenesis

imperfecta• Others: Fragile X syndrome, Martin-Bell syndrome, Polycystic kidney disease (adult type), Periarteritis nodosa

Fauci, et al. 2008. Harrison’s Principles of Internal Medicine, 17th ed.Venugopalan. 2008. Mitral Valve Prolapse.

<http://emedicine.medscape.com/article/890425-overview>

5. When do you give prophylactic treatment in MVP?

Clinical approach to determination of the need for prophylaxis in patients with

suspected MVP

Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association

A reasonable approach for endocarditis prophylaxis should consider the following: the degree to which the patient’s underlying

condition creates a risk of endocarditis the apparent risk of bacteremia with the procedure the potential adverse reactions of the prophylactic

antimicrobial agent to be used; and the cost-benefit aspects of the recommended prophylactic regimen

Failure to consider all of these factors may lead to overuse of antimicrobial agents, excessive cost, and risk of adverse drug reactions


Prophylaxis is recommended in individuals who have a higher risk for developing endocarditis than the general population and is particularly important for individuals in whom endocardial infection is associated with high morbidity and mortality



Endocarditis prophylaxis recommendedHigh-risk category Prosthetic cardiac valves Previous bacterial endocarditis Complex cyanotic congenital heart

diseaseEg. Single ventricle states,

Transposition of the great arteries, Tetralogy of Fallot

Surgically constructed systemic pulmonary shunts or conduits


Moderate-risk category Acquired valvular dysfunction (eg,

rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular

regurgitation and/or thickened leaflets


Endocarditis prophylaxis NOT recommendedNegligible-risk category Isolated secundum atrial septal defect Surgical repair of ASD, VSD or PDA Previous coronary artery bypass graft

surgery Mitral valve prolapse without valvular

regurgitation Physiologic, functional, or innocent heart

murmurs Previous Kawasaki disease without valvular

dysfunction Previous rheumatic fever without valvular

dysfunction Cardiac pacemakers and implanted

defibrillatorsPrevention of Bacterial Endocarditis: Recommendations by the

American Heart Association

Prophylaxis Prophylaxis at the time of cardiac surgery

should be directed primarily against staphylococci and should be of short duration

First-generation cephalosporins are most often used

Prophylaxis is most effective when given perioperatively in doses that are sufficient to assure adequate antibiotic concentrations during and after the procedure

Antibiotics should be used only during the perioperative period - initiated shortly before a procedure and should not be continued no more than 6 to 8 hours

In the case of delayed healing, or of a procedure that involves infected tissue, it may be necessary to provide additional doses of antibiotics

Prophylaxis

Antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis


Streptococcus viridans is the most common cause of endocarditis following: dental or oral procedures certain upper respiratory tract

procedures bronchoscopy with a rigid bronchoscope surgical procedures that involve the

respiratory mucosa esophageal procedures


The recommended standard prophylactic regimen for all these procedures is a single dose of oral amoxicillin to be administered 1 hour before the anticipated procedure Adult dose is 2.0 g Pediatric dose is 50 mg/kg (not to exceed adult

dose) For individuals who are unable to take or

unable to absorb oral medications, parenteral Ampicillin sodium is recommended

Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

Individuals who are allergic to penicillin Clindamycin hydrochloride Azithromycin or clarithromycin

When parenteral administration is needed in an individual who is allergic to penicillin, clindamycin phosphate is recommended

Durack DT. Prevention of infective endocarditis. N Engl J Med. 1995

Prophylaxis Enterococcus faecalis is the most

common cause of bacterial endocarditis that occurs following genitourinary and gastrointestinal tract surgery or instrumentation

Antibiotic prophylaxis should be directed primarily against Enterococci




High-risk patients Ampicillin plus gentamicin

High-risk patients allergic to ampicillin/amoxicillin Vancomycin plus gentamicin

Moderate-risk patients Amoxicillin or ampicillin

Moderate-risk patients allergic to ampicillin/amoxicillin Vancomycin


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Mitral Valve Prolapse