Slide 1

1

Mitral Valve Prolapse and RegurgitationJason Infeld, MD, FACCStern Cardiovascular Foundation2

DISCLOSUREJason InfeldMD, FACCStern Cardiovascular Foundation

I have the following personal financial relationships with commercial interests to disclose:

NONE3

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 controversyMany common perceptions about this disease have been recently been shown to be falseDisease was widely overdiagnosed in the 70s and 80s as echocardiography became more widely available44

What is MVP?Systolic bowing of one or both mitral valve leaflets across the plane of the mitral valve annulus into the LADisease is often benign, but may be associated severe complications including mitral regurgitation, endocarditis, and arrythmias. 55

Freed L et al. N Engl J Med 1999;341:1-7Classic Mitral-Valve Prolapse during Systole

6Figure 1. Classic Mitral-Valve Prolapse during Systole.

The parasternal long-axis view shows the mitral leaflets prolapsing (>2 mm), as indicated by the dotted line, into the left atrium during systole. LA denotes left atrium, and LV left ventricle.

Freed L et al. N Engl J Med 1999;341:1-7Classic Mitral-Valve Prolapse with Leaflet Thickening (Arrows) during Diastole7Figure 2. Classic Mitral-Valve Prolapse with Leaflet Thickening (Arrows) during Diastole.

The parasternal long-axis view demonstrates mitral-leaflet thickening (>=5 mm) during diastole. LA denotes left atrium, and LV left ventricle.

How common is MVP?Early prevalence estimates between 5 and 20% and up to 35% in some studiesDisease was thought to be more common in young womenStudies were faulty due to severe selection bias and a lack of clear echocardiographic criteria

88

History of MVPDescribed accurately in the 60s 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 entityEarly studies shows prevalence as high as 35%Mitral valve fiasco9

History of MVP1980s widespread use of 2-dimensional echoUse of apical 4-chamber view continued to lead to significant overdiagnosis1987 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 diagnosis10

PrevalenceFramingham study - prevalence approximately 1.1%Reviewed echos of 3591 men and women5 to 1 ratio of self-reported diagnosis of MVP and echocardiographic MVPPrevalence equal between men and womenMVP patients were thinner and had more MRAverage amount of MR was trace to mild1111

Echocardiography

Apical 4-chamber viewParasternal Long-axis View

1212

1313

14

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 leaflet1515

EchocardiographyClassical vs. nonclassic MVP>2mm displacement and >5mm thickness are considered to have classic MVPPatients with leaflet thickeness 40 mmFlail leafletAtrial fibrillation (AF)Age >50 years.

2222

23

2006 ACC/AHA GuidelinesRepeat 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 MRClinical evaluation and echocardiography at any time there is a change in signs of symptoms.

2424

Treatment of MVP25

Endocarditis ProphylaxisThe 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 endocarditis26

Treatment and F/u of MR27274/4/13

4/4/13

Chronic Mitral RegurgitationMost patients asymptomatic even with severe MRProgressive dilatation of the LA and LV. LA enlargement may result in atrial fibrillationModerate to severe MR may eventually result in LV dysfunction and development of CHFPulmonary hypertension may occur with associated right ventricular dysfunction. Typically prolonged asymptomatic intervalMaybe an accelerated phase as a result of ruptured mitral valve chordae leading to progressive left atrial and LV dysfunction and atrial fibrillation

30

Goals of TreatmentPrevent irreversible LV dysfunction, pulmonary HTN, or atrial fibrillation in an asymptomatic patientRelieve symptoms of dyspnea and fatigue in symptomatic patientsPrevent sudden cardiac death31

3232

3333

3434

Mitral Valve Repair vs Replacement35

Mitral Valve RepairIdeal treatment for mitral regurgitation.Avoids need for anticoagulation and long-term risks of valve prosthesisPreserves mitral valve anatomy leading to better post-operative LV function and survivalRepair is surgeon specific and success is highly correlated with volume36

Clinician needs to be able to determine the likelihood of repairIsolated posterior leaflet prolapse more amenable to repairPresence of severe anterior leaflet prolapse, severe valve thickening and calcification make repair less likelyTEE is recommended pre-operatively to define pathology and mechanism of MRMitral Valve Repair37

How is it done?38

3939

40

The Robot4141

4242

Flail Mitral LeafletSubset of patients who do clinically worse even in the absence of progressive LV dilatation or dysfunction.Higher-risk of sudden cardiac deathReferral for early surgical treatment if valve amenable to repair.43

Flail Mitral Leaflet44

TEEPlays an important role in the evaluation of MR due to the proximity of the TEE probe to the LATTE can underestimate MR due to shadowing from calcification and prosthetic valvesDefines mechanism and severity of MRIdeal test to assess if repair is feasible

45

46

474/4/13

4/4/13

4/4/13

Questions?51