Mild expression of mitral valve prolapse in the Framingham offspring: expanding the phenotypic spectrum.

BACKGROUND: Mitral valve (MV) prolapse (MVP) is a common disorder associated with mitral regurgitation, endocarditis, heart failure, and sudden death. Nondiagnostic morphologies have been described in the familial context and may represent early expression of MVP in those genetically predisposed. The aim of this study was to explore the spectrum of MVP abnormalities in the community and compare their clinical and echocardiographic features. METHODS: We measured annular diameter MV leaflet displacement, thickness, anterior and posterior leaflet projections onto the annulus, MV leaflet coaptation height (posterior MV leaflet projection/annular diameter), and MR jet height in 296 individuals of the Framingham Offspring Study with MVP (n = 77), the "abnormal anterior coaptation" (AAC) phenotype (n = 11) or "minimal systolic displacement" (MSD) (n = 57), and 151 age-matched and sex-matched referents with no MVP or its nondiagnostic forms. RESULTS: AAC did not meet diagnostic displacement criteria but resembled MVP with regard to annular diameter and leaflet thickness (P > .05 for both). AAC was similar to posterior MVP with regard to posterior leaflet asymmetry and an anteriorly shifted coaptation (P = .91). Compared to patients with MSD and referents, patients with AAC had greater leaflet coaptation height, thickness, and annular diameter (P < .05 for all). MSD shared the posterior leaflet asymmetry with MVP, but the coaptation point was more posterior (coaptation height = 31% vs. 42%, P < .0001), as seen in referents. A higher proportion of patients with MVP had jet height ≥ 2 mm (mild or greater MR) compared with the other participants (44% vs. 16%, P < .0001). CONCLUSIONS: Nondiagnostic morphologies are observed in the community and share the common feature of posterior leaflet asymmetry with MVP. AAC and MSD may thus represent early expressions of MVP. Longitudinal studies are warranted to elucidate the natural history of these phenotypes.

Noninvasive clinical assessment of systolic torsional motions by two-dimensional speckle-tracking echocardiography in dogs with myxomatous mitral valve disease.

BACKGROUND: Left ventricular torsional motion plays an important role for effective pump function. However, noninvasive clinical assessment of torsional deformations by two-dimensional speckle-tracking echocardiography (2D-STE) in dogs with myxomatous mitral valve disease (MMVD) has not been reported. HYPOTHESIS: Left ventricular torsion is determined by the native orientation of the helical myocardial fibers, such that it might provide better assessment of myocardial function than conventional methods. ANIMALS: Sixty-seven client-owned dogs with MMVD were classified into 3 classes based on the International Small Animal Cardiac Health Council classification and 16 weight- and age-matched healthy dogs. METHODS: Dogs were examined for myocardial deformations by 2D-STE and were evaluated for peak systolic rotation and rotation rate at each basal and apical view. Dogs also were evaluated for peak systolic torsion and torsion rate. RESULTS: Peak systolic torsion was higher in class II than in class I (P < .001) dogs. Peak systolic torsion was lower in class III than in class II (P = .001) dogs and controls (P = .003). CONCLUSIONS AND CLINICAL IMPORTANCE: Torsional deformations assessed by 2D-STE differed among clinical classes of MMVD. Myocardial torsional deformations by 2D-STE may provide more detailed assessment of contractile function in dogs with MMVD.

[Diagnosis and classification of mitral valve prolapse in children and adolescents].

We examined 1734 children and adolescents with admittance diagnosis mitral valve prolapse (MVP) and confirmed its presence using accepted Framingham criteria in 32.3% of cases. Reason for overdiagnosis in other cases was incorrect interpretation of auscultation or echocardiography data. Most often MVP was familial with recessive or dominant inheritance according to genealogical analysis. Contrary to MVP in adults children and adolescents commonly had no myxomatous transformation of valves. Taking into account constitutional and physiological peculiarities of the body in children and adolescents we distinguished two forms of MVP characteristic for this age: MVP as a variant of asthenic constitution and physiological MVP. Both forms are widely spread and represent normal states for juvenile population.

Current concepts in mitral valve prolapse--diagnosis and management.

Although mitral valve prolapse as a disease entity has been recognized for over 50 years, its precise definition has been elusive. Initial reports based the diagnosis on auscultatory findings (late systolic click - murmur), with left ventricular angiography as a confirmative test. Echocardiography, first the M-mode, and subsequently the two-dimensional, became the dominant diagnostic modality. However, the early reports did not distinguish between billowing valve and flail valve. The advent of surgical repair techniques provided a different perspective; the surgical definition of mitral valve prolapse is often different from that of cardiologists. Intraoperative echocardiography gained wide acceptance necessitating a common language to describe precise terminology of the leaflet anatomy and definition of valve prolapse. The present report proposes a terminology and definitions of valve prolapse with relevance to surgical mitral valve repair. The addition of real-time 3D transesophageal echocardiography now provides highly accurate localization of lesions and the multi segment assessment of valve pathology. The etiologic considerations and surgical repair techniques with the role of echo - surgery team in improved patient outcome are described.

Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era.

BACKGROUND: Factors predicting long-term survival and reoperative risk after mitral valve repair for subsets with prolapse involving the anterior leaflet in the current era are unclear. METHODS: Between January 1, 1980 and December 31, 1999, surgical correction of mitral regurgitation was performed in 2,219 patients. We analyzed a subset of 1,411 patients with isolated mitral regurgitation due to leaflet prolapse undergoing mitral repair or replacement (+/- coronary bypass). RESULTS: Mean age was 64 years, and 1,003 (71%) were men. Mitral repair was performed in 1,173 (83%) patients. Factors independently predicting overall long-term survival included valve repair, younger age, better functional class, and the absence of significant coronary artery disease. After adjusting for these, smaller preoperative left ventricular end-systolic dimension and greater preoperative ejection fraction were associated with superior survival. Mitral reoperation occurred in 97 patients (75 repairs, 22 replacements), at a mean of 4.8 years after initial procedure. Cumulative risk of reoperation was similar for patients having valve repair or replacement. Factors predictive of need for reoperation after initial repair were younger age, anterior leaflet prolapse, chordal shortening, no leaflet resection, no prosthetic annuloplasty, greater than mild residual mitral regurgitation, and coronary artery disease. After valve replacement, the sole determinant of reoperation was use of a biological prosthesis. The durability of repair for prolapse of the anterior leaflet improved significantly during the second decade of the study. CONCLUSIONS: Mitral repair affords superior long-term survival, with permanence comparable with mechanical valve replacement. In all categories of mitral leaflet prolapse, durability of valve repair has improved over the past decade.

Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study.

OBJECTIVE: The aim of this study was to examine the echocardiographic features and associations of mitral valve prolapse (MVP) diagnosed by current two-dimensional echocardiographic criteria in an unselected outpatient sample. BACKGROUND: Previous studies of patients with MVP have emphasized the frequent occurrence of echocardiographic abnormalities such as significant mitral regurgitation (MR) and left atrial (LA) enlargement that are associated with clinical complications. These studies, however, have been limited by the use of hospital-based or referral series. METHODS: We quantitatively studied all 150 subjects with possible MVP by echocardiography and 150 age- and gender-matched subjects without MVP from the 3,491 subjects in the Framingham Heart Study. Based on leaflet morphology, subjects were classified as having classic (n = 46), nonclassic (n = 37), or no MVP. RESULTS: Leaflet length, MR degree, and LA and left ventricular size were significantly but mildly increased in MVP (p < 0.0001 to 0.004), with mean values typically within normal range. Average MR jet area was 15.1 +/- 1.4% (mild) in classic MVP and 8.9 +/- 1.5% (trace) in nonclassic MVP; MR was severe in only 3 of 46 (6.5%) subjects with classic MVP, and LA volume was increased in only 8.7% of those with classic MVP and 2.7% of those with nonclassic MVP. CONCLUSIONS: Although the echocardiographic characteristics of subjects with MVP in the Framingham Heart Study differ from those without MVP, they display a far more benign profile of associated valvular, atrial, and ventricular abnormalities than previously reported in hospital- or referral-based series. Therefore, these findings may influence the perception of and approach to the outpatient with MVP.

Clinical, echocardiographic, and biomechanical differences in mitral valve prolapse affecting one or both leaflets.

Mitral valve prolapse (MVP) is the most common cause of severe mitral regurgitation necessitating surgical correction. Unileaflet prolapse (ULP), usually involving the posterior leaflet, is more common than bileaflet prolapse (BLP), which is more difficult to repair. Little is known about clinical, echocardiographic, and biomechanical differences between ULP and BLP. In this study, biomechanical testing was performed on mitral valve leaflets and chordae obtained at operation for severe mitral regurgitation. Preoperative clinical characteristics and echocardiographic measurements were obtained on surgical patients (ULP = 88, BLP = 37). Men outnumbered women by a factor of 4:1 in ULP, and by 3:1 in BLP. Patients with BLP were younger (53.2 +/- 1.7 vs 59.5 +/- 1.1 years) than those with ULP, and this difference was greater in women (48.9 +/- 2.5 vs 62.9 +/- 2.2 years). BLP patients were less likely to be hypertensive, and more likely to undergo valve replacement rather than repair. Echocardiography showed that BLP leaflets were longer and thicker than ULP leaflets. The severity of mitral regurgitation was similar in both groups, although ULP patients had a much higher incidence of flail leaflets (45% vs 5% in BLP). Mechanical strength of chordae was greater in BLP than in ULP, although leaflet strength was similar. The increased chordal strength in BLP may be responsible for less flail. In patients with MVP and severe mitral regurgitation requiring surgery, ULP and BLP are distinct entities with substantial differences in the population affected, in echocardiographic manifestations including prevalence of flail, in chordal mechanics, and in the likelihood of surgical repair.

[A patient with mitral prolapse: differential intervention programs in general medical practice]. / Patsient s prolabirovaniem mitral'nogo klapana: differentsirovannye programmy vmeshatel'stva v obshchei vrachebnoi praktike.

AIM: To develop and implement intervention programmes for patients with mitral prolapse (MP) under real conditions of general medical practices of Russia in the transition period. MATERIAL AND METHODS: The MP register covered 208 patients among the adult population (n = 3346) of 2 districts served by general practitioners. According to the formalized protocols, clinical, instrumental, and psychological studies were conducted, which included examination of complaints and physical status, electrocardiography, echocardiography, paired echocardiography before and after bicycle ergometry exercise tests, psychological testing, study of the social status and life quality of patients. RESULTS: According to clinical and instrumental findings, the patients were divided into 4 groups, where differential individually based intervention programmes were implemented; the latter included modules of family upbringing, family prophylaxis, drug and nondrug treatment. Psychotherapeutical potentiation was performed in patients with the low cooperation index on an individual basis in accordance with revealed personality traits. Clinical symptoms diminished in severity, scores on pathological disease attitude scales lowered, life quality increased, persons with the low cooperation index reduced in number. CONCLUSION: The developed and tested intervention programmes in patients with MP are effective and may be successfully implemented in general medical practice facilities.

Current management of mitral valve prolapse.

Mitral valve prolapse is a pathologic anatomic and physiologic abnormality of the mitral valve apparatus affecting mitral leaflet motion. "Mitral valve prolapse syndrome" is a term often used to describe a constellation of mitral valve prolapse and associated symptoms or other physical abnormalities such as autonomic dysfunction, palpitations and pectus excavatum. The importance of recognizing that mitral valve prolapse may occur as an isolated disorder or with other coincident findings has led to the use of both terms. Mitral valve prolapse syndrome, which occurs in 3 to 6 percent of Americans, is caused by a systolic billowing of one or both mitral leaflets into the left atrium, with or without mitral regurgitation. It is often discovered during routine cardiac auscultation or when echocardiography is performed for another reason. Most patients with mitral valve prolapse are asymptomatic. Those who have symptoms commonly report chest discomfort, anxiety, fatigue and dyspnea, but whether these are actually due to mitral valve prolapse is not certain. The principal physical finding is a midsystolic click, which frequently is followed by a late systolic murmur. Although echocardiography is the most useful mode for identifying mitral valve prolapse, it is not recommended as a screening tool for mitral valve prolapse in patients who have no systolic click or murmur on careful auscultation. Mitral valve prolapse has a benign prognosis and a complication rate of 2 percent per year. The progression of mitral regurgitation may cause dilation of the left-sided heart chambers. Infective endocarditis is a potential complication. Patients with mitral valve prolapse syndrome who have murmurs and/or thickened redundant leaflets seen on echocardiography should receive antibiotic prophylaxis against endocarditis.

[Fundamentals and indications for mitral valve repair surgery]. / Fondements et indications de la chirurgie réparatrice dans les valvulopathies mitrales.

The concept of mitral valve repair is discussed, emphasizing the basic knowledge on which it relies, and the breakthrough it has produced in modern cardiac surgery. This concept challenges the myth of the artificial prosthesis, showing the superiority of autologous biological structures submitted to plastic repair. The foundations of valvular repair and the techniques that have contributed to its success are reviewed, and the advantages for the patients in terms of quality of life, and preservation of the left ventricular function are discussed.

Prevalence and clinical outcome of mitral-valve prolapse.

BACKGROUND: Mitral-valve prolapse has been described as a common disease with frequent complications. To determine the prevalence of mitral-valve prolapse in the general population, as diagnosed with the use of current two-dimensional echocardiographic criteria, we examined the echocardiograms of 1845 women and 1646 men (mean [+/-SD] age, 54.7+/-10.0 years) who participated in the fifth examination of the offspring cohort of the Framingham Heart Study. METHODS: Classic mitral-valve prolapse was defined as superior displacement of the mitral leaflets of more than 2 mm during systole and as a maximal leaflet thickness of at least 5 mm during diastasis, and nonclassic prolapse was defined as displacement of more than 2 mm, with a maximal thickness of less than 5 mm. RESULTS: A total of 84 subjects (2.4 percent) had mitral-valve prolapse: 47 (1.3 percent) had classic prolapse, and 37 (1.1 percent) had nonclassic prolapse. Their age and sex distributions were similar to those of the subjects without prolapse. None of the subjects with prolapse had a history of heart failure, one (1.2 percent) had atrial fibrillation, one (1.2 percent) had cerebrovascular disease, and three (3.6 percent) had syncope, as compared with unadjusted prevalences of these findings in the subjects without prolapse of 0.7, 1.7, 1.5, and 3.0 percent, respectively. The frequencies of chest pain, dyspnea, and electrocardiographic abnormalities were similar among subjects with prolapse and those without prolapse. The subjects with prolapse were leaner (P<0.001) and had a greater degree of mitral regurgitation than those without prolapse, but on average the regurgitation was classified as trace or mild. CONCLUSIONS: In a community based sample of the population, the prevalence of mitral-valve prolapse was lower than previously reported. The prevalence of adverse sequelae commonly associated with mitral-valve prolapse in studies of patients referred for that diagnosis was also low.

[Echocardiographic evaluation of mitral system and complications of mitral prolapse]. / Ekhokardiograficheskaia otsenka sostoianiia mitral'nogo apparata i oslozhneniia prolabirovannogo mitral'nogo klapana.

AIM: The analysis of echo-CG morphology of the mitral system in patients with uncomplicated mitral prolapse (MP) in the presence and absence of mitral regurgitation and in patients with severe complications. MATERIALS AND METHODS: Echo-CG was made in 116 patients with MP: with uncomplicated (87) and complicated (29) MP, with infectious endocarditis (13), thromboembolism (6), congestive circulation failure (10). MP was diagnosed according to the standard criteria with visualization of the mitral valve from the parasternal approach. RESULTS: Mitral picture is detailed for 87 MP patients. Classification of the degree of myxomatous degeneration is proposed. 17 MP patients were exposed to loading echocardiography. Exercise may provoke transitory mitral regurgitation. Mitral status has been analysed in patients with serious MP complications. CONCLUSION: The relationship may exist between MP complications, severity of myxomatous degeneration of the mitral valve and the presence of any kind of mitral regurgitation.

Mitral valve prolapse syndrome: interventions for symptom control.

Mitral valve prolapse syndrome, the most common valvular disorder, is associated with symptoms of anxiety, fatigue, palpitations, headaches, chest pain and more. Many non-drug interventions can be employed to alleviate symptoms.