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Mitral valve prolapse: diagnosis, treatment and natural course

Regina Jonkaitien, Rimantas Benetis1, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

Clinic of Cardiology, 1Clinic of Cardiac Surgery, Kaunas University of Medicine, Lithuania

Key words: mitral valve prolapse, natural course, complications, surgical treatment, mitral

valve repair.

Summary. This article analyzes data obtained from the medical records of the patients with

primary mitral valve prolapse. The study population was the patients admitted to Kaunas

University of Medicine Heart Center (KUMHC) between 1999 and 2003. The objective of our

study was to analyze the natural course of mitral valve prolapse, complications and their frequency,

treatment strategy in KUMHC, as well as to review the results of surgical treatment.

We gathered data from the medical records of 160 patients and analyzed their age, medical

history, complications, comorbidities, functional status and echocardiographic parameters.Patients who underwent mitral valve surgery were followed 7.98.4 months after procedure.

On average, 3214 patients with primary mitral valve prolapse were treated at KUMHC

annually. Their mean age was 48.416.5 years, 44.4% of them were male. The most frequent

complications of mitral valve prolapse were II mitral regurgitation (78.4%), various cardiac

arrhythmias (68.1%) and heart failure of II NYHA class (79%). Surgical treatment was

recommended for 64 (40%) KUMHC patients with primary mitral valve prolapse. Surgical

treatment was applied in 44 (28.1%) of study patients. The patients, who were recommended

surgical treatment, were older (mean age 53.211.9 years, p

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dies show that more than one half of the patients with

MPV are asymptomatic and usually have benign

course of the disease. Their overall morbidity and mor-

tality is similar to general population (3). However,

in the remaining portion of cases MVP may be asso-

ciated with severe cardiovascular complications, suchas progressive mitral regurgitation, arrhythmias, heart

failure, increased risk of infective endocarditis and

7.8% of the patients with MVP require mitral valve

surgery (3). Different authors from various centers

had provided variable data concerning MVP course,

complications and their frequency (37). Any clini-

cal or epidemiological studies on MVP have not been

conducted in Lithuania so far, hence the MVP clini-

cal course, treatment strategy and results, own surgi-

cal treatment experience have not been analyzed.

There are no generally accepted criteria for theoptimal timing of mitral valve surgery in MVP. Indi-

cations for the MPV surgical treatment in Kaunas

University of Medicine Heart center (KUMHC) were

outlined following ACC/AHA Guidelines for the

Management of Patients with Valvular Heart Disease

(published in 1998 (1)) and ESC Working Group Rec-

ommendations on the Management of the Asympto-

matic Patient with Valvular Heart Disease (published

in 2002 (8)). These guidelines are based upon exten-

sive worldwide experience and the results of the mi-

tral regurgitation surgical treatment. However, major-ity of the studies on which the guidelines are based

have not separated patients with mitral valve prolapse.

Moreover, majority of the specialists (9, 10) note that

indications for the surgical treatment of mitral valve

prolapse as well as the timing of the surgery should

be based upon the experience and the results in par-

ticular hospital. Therefore, analysis of surgical expe-

rience in our medical center is important.The objective of this study was to analyze the natu-

ral course of mitral valve prolapse, its complications

and their frequency, the management strategy, as well

as experience and results of the surgical treatment at

KUMHC.

Patients and methods

The records of a total of 160 subjects (mean age

48.416.5 years, 44.4% male) with primary MVP

hospitalized in KUMHC from 1999 to 2003 were ana-

lyzed. The diagnosis of MVP was made by the phy-

sical examination (midsystolic or telesystolic clickwith a systolic murmur on the heart auscultation) and

two-dimensional echocardiography. Two-dimensional

echocardiography was performed in all patients. Then

transesophageal two-dimensional echocardiography

was performed in 31.2% of study patients to confirm

the diagnosis. Echocardiographic diagnosis of MVP

was made using Freed et al. criteria (6).

Patients with the secondary MVP due to coronary

heart disease or rheumatic heart disease were ex-

cluded. Associated incidental coronary artery disease

was not an exclusion criterion.In the medical records of patients with primary

MVP we looked at the age, past medical history,

Fig. 1. Normal mitral valve (A) and posterior leaflet prolapse (B)

AL anterior leaflet of mitral valve; PL posterior leaflet; PA pulmonary artery; Ao aorta.

A B

Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

Medicina (Kaunas) 2005; 41(4)

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1999 2000 2001 2002 2003

-60

-40

-20

0

20

40

Percent(fromhospitalized

patientswithMVP)

Surgery

recommended

(primary axis)

Underwentsurgery

(primary axis)

Rejected

surgery

(primary axis)

Hospitalized

with MVP

(secondary

axis)

Percent

(fromhospitalizedpatientsw

ithMVP)

Percent(frompatientswith

MVP

hospitalizedduringparticularyear)

Year

70

60

50

40

30

20

10

0

40

20

0

comorbidities, complications of mitral valve prolapse,

as well as patients functional state according to New

York Heart Association (NYHA) classification, and

echocardiographic measurements (such as end-dias-

tolic left ventricle dimension (EDLVD), left atrium dia-meter (LA), left ventricle ejection fraction (EF) by

Simpsons method, the degree of mitral regurgitation).

We also evaluated the change of two-dimensional

echocardiographic findings over five years in opera-

tively managed patients. Patients who underwent mitral

valve surgery were followed up in average for 7.98.4

months (from 2 to 39 months) after procedure.

Statistical analysis was performed using STATIS-

TICA 5.0 software. Quantitative values were mean

and standard deviation. The comparison of data from

groups of recommended either medical management

or surgical, as well as the group of operated patients

versus those who refused surgery was performed us-

ing Students t-test for the independent samples. Com-

parison between two-dimensional echocardiographic

findings before and after surgery was made using Stu-

dents t-test for dependent samples. The difference

between two variables was considered statistically

significant if p value was equal or less than 0.05. All

p tests were two-sided.

Results

Data analysis shows that between 1999 and 2003,3214 patients with primary mitral valve prolapse

were hospitalized annually in KUMHC. Surgical treat-

ment was recommended to 64 (40%) patients. Sur-

gery was performed in 45 (28.1%) of all MPV pa-

tients treated in KUMHC during study period, which

was annually 96.4 of these patients. 19 (29.7%) of

all patients who were referred for an operative treat-

ment refused surgery.

The rate of the hospitalizations due to MVP in-

creased 3.2 times (7.5% to 23.7%) in 5-year periodsince 1999. And the number of patients who were re-

ferred for the heart surgery increased 3.3 times (from

16.7% to 55.3%). The number of patients who under-

went surgery was 2.8 times bigger in 2003 than in

1999 (Fig. 2).

The study population was divided into 4 groups:

patients to whom medical management was rec-

ommended,

patients to whom surgical management was rec-

ommended,

the group of patients who underwent surgery,

and the group of patients who refused surgery.

The summary of the clinical characteristics of these

4 groups is shown in Table 1.

All study patients were further divided into two

groups according to their NYHA functional status

(NYHA III and NYHA IIIIV) and into four groups

according to the degree of mitral regurgitation. In or-

der to estimate the rate of progression of mitral regur-

gitation and heart failure in MVP patients, the mean

age was calculated and compared in all subgroups

mentioned above. 103 (64.4%) patients were assigned

to NYHA III group, their mean age was 42.014.8years; respectively 57 (35.6%) patients were assigned

to NYHA IIIIV group, mean age 59.813.1 years

(p

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Total Medical Group of Surgical Group of Features n=160 manage- patients p treatment patients p

(%) ment referred group whogroup for surgical n=44** rejectedn=96 (%) treatment (%) surgery

n=64 (%) n=19 (%)

Male 71 (44.4) 31 (32.3) 40 (62.5) 0.0002* 27 (61.4) 12 (63.1) 0.88Female 89 (55.6) 65 (67.7) 24 (37.5) 0.0002* 17 (38.6) 7 (36.8) 0.88Age (mean SD) 48.416.5 43.917.7 55.111.8

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2.8

8.3

13.9

30.5

44.4

0

10

20

30

40

50

Percent

1999 2000 2001 2002 2003 Years

Analysis of two-dimensional echocardiography

measurements up to 40 months after surgery revealed

that EDLVD significantly decreased over 26 months

after surgery (8.83.7 mm, p

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to the rest of the patients with MVP. Recent worldwide

populational studies showed that the prevalence of

MVP in general population was rather low: 0.62.4%

(6, 11).

The hospitalization rate, the need for surgical treat-

ment and the number of mitral valve surgeries due to

MVP are growing every year, despite low MVP pre-

valence. They increased near 3 times over the past 5

years. This can be attributed to the improvement in

the technique of cardiac surgery in KUMHC. The

frequency of the surgical mitral valve repair is incre-asing every year. Moreover, the opinion of the cardio-

logists about surgical treatment of MVP has changed,

and because of the new clinical research (9) mitral

valve surgery is more frequently recommended for

asymptomatic and minimally symptomatic patients

with severe mitral regurgitation. These patients are more

likely to have better long-term survival than symp-

tomatic patients (NYHA functional class III or IV).

In our study the mean age of patients with primary

MVP was 48.4 years. Etiology of primary MVP is

associated with the genetic factors (1214). The natu-

ral course of the disease is rather benign. Symptoms

and complications usually appear only after 40 or 50years of age. The patients to whom surgical treatment

was recommended were significantly older than the

Fig. 4. Postoperative changes of two-dimensional echocardiographic measurements

Fig. 5. Postoperative change of the degree of mitral regurgitation

1 1 26 712 1340

4.5

3.5

2.5

1.5

0.5

0.5

4

3

2

1

0

Months after sugery

MRdegree

LAdimension,EDLVD(mm)

Months after sugery

20

30

40

50

60

70

80

40

50

60

70

80

90

100

EF(perc.)

Long dimension

of LA

Short dimension

of LA

EDLVD

EF

EF(perc.)

1 1 26 712 1340

40

50

60

70

80

90

100



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patients in medical management group (mean age 55.1

vs. 43.9 years, respectively; p

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tion, and were more symptomatic than the patients in

medical management group. EF less than 50% was

found in 15% of the first group patients vs. 3.7% of

patients in the second group (p=0.02). Mitral regur-

gitation of III or worse was prevalent 95.3% and16.8% respectively (p=0.0001). NYHA functional class

III or IV was found significantly more prevalent in

the group of patients who were recommended surgical

treatment than in medical management group (62.5

vs. 16.7%; p

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parison of clinical characteristics between the groups

of the patients who underwent surgery and those who

resigned it revealed that both groups had the same

demographic data (sex, age) as well as similar comor-

bidities. Though III mitral regurgitation was moreprevalent in the group that rejected surgery (63.1 vs.

36.4%; p=0.05), both groups had the same NYHA

functional class and EF. Therefore, we can conclude

that the reasons to reject surgery were subjective and

dependent on persons fear of surgery itself as well as

its complications. This fear in turn is caused by the

lack of information about natural course of this disea-

se, treatment options and good results of the surgical

treatment.

Conclusions

1. Though symptomatic primary mitral valve pro-

lapse is not a common disease the hospitalization rate

and number of heart surgeries due to mitral valve pro-

lapse is growing steadily every year.

2. The most common causes of the hospitalization

in MVP patients were: development of mitral regurgi-

tation, severe mitral insufficiency, cardiac arrhythmias

and heart failure. More than one third of patients with

mitral valve prolapse required heart surgery.3. Number of mitral valve repairs is growing stea-

dily in KUMHC every year.

4. The remodeling of the left ventricle and the left

atrium occurred during six months after mitral valve

surgery. At that time the echocardiography measure-

ments of left heart were decreasing, mitral regurgita-

tion was not increasing and these positive changes

remained during all study period (40 months).

5. Taking in the consideration the large number of

mitral valve repair procedures and good outcomes,

the low postoperative mortality, as well as regression

of the left heart dilatation after surgery, we can strongly

recommend surgical treatment in KUMHC for the pa-

tients with severe mitral regurgitation secondary to

mitral valve prolapse.

Mitralinio votuvo prolapso diagnostikos, gydymo ir eigos ypatybs

Regina Jonkaitien, Rimantas Benetis1, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

Kauno medicinos universiteto Kardiologijos klinika, 1Kardiochirurgijos klinika

Raktaodiai: mitralinio votuvo prolapsas, eigos ypatybs, komplikacijos, chirurginis gydymas, mitraliniovotuvo plastika.

Santrauka.Straipsnyje nagrinjami duomenys apie 19992003 metais Kauno medicinos universiteto klinikirdies centre dl pirminio mitralinio votuvo prolapso gydytpacientskaii, jklinikines charakteristikas,chirurgin gydym.

Darbo tikslas. Ianalizuoti pirminio mitralinio votuvo prolapso eigos ypatybes, komplikacijas bei jdan,Kauno medicinos universiteto klinikirdies centre taikomgydymo taktik, chirurginio gydymo rezultatusbei patirt.

Ianalizuota 160 pacientmedicinin dokumentacija: vertintas tiriamjamius, anamnez, komplikacijosir gretutins ligos, funkcin bkl, echokardiografiniai rodmenys. Operuotligoniechokardiografinirodmen

dinamika stebta 7,98,4 mnesio po mitralinio votuvo korekcijos operacijos.Kauno medicinos universiteto klinikirdies centre kasmet gydyta 3214 pacient, kuriems diagnozuotaspirminis mitralinio votuvo prolapsas, jamius 48,416,5 met, 44,4 proc. iligoni vyrai. Daniausiosmitralinio votuvo prolapso komplikacijos buvo II arba didesnio laipsnio mitralinio votuvo nesandarumas(78,4 proc.), vairs irdies ritmo sutrikimai (68,1 proc.), II arba didesnio laipsnio NYHA funkcins klassirdies nepakankamumas (79 proc.). Chirurginis gydymas rekomenduotas 64 (40 proc.) Kauno medicinosuniversiteto klinikirdies centre gydytiems pacientams, kuriems diagnozuotas pirminis mitralinio votuvoprolapsas. Operuoti 44 (28,1 proc.) tiriamieji. Lyginant su konservatyvaus gydymo grupe, didesndalpacient,kuriems rekomenduotas chirurginis gydymas, sudar vyrai (62,5 proc.). ie pacientai buvo vyresni (amiausvidurkis 55,111,8 met), jiems buvo rykesni irdies nepakankamumo simptomai (62,5 proc. IIIIVNYHA funkcins klass), didesnio laipsnio mitralin regurgitacija (95,3 proc. regurgitacija buvo III ir didesniolaipsnio) ir blogesn kairiojo skilvelio funkcija (15 proc. nustatyta istmimo frakcija maiau nei 50 proc.)(vismintrodmenskirtumo tarp grupip

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mitralinio votuvo plastikskaiius 15,8 karto. Pooperacin eiga 56,8 proc. pacientbuvo sklandi. Daniausiapooperacin komplikacija nauji irdies ritmo ir laidumo sutrikimai. Ankstyvuoju pooperaciniu laikotarpiumir vienas pacientas. Per 26 mnesius po mitralinio votuvo operacijos ymiai sumajo kairiojo skilvelioir kairiojo prieirdio matmenys bei mitralins regurgitacijos laipsnis ir ie teigiami pakitimai iliko vis

stebjimo laikotarp

.vertinus mapooperacinmirtamum, chirurginio gydymo efektyvum, mitralinio votuvo plastiksan-

tykin dan ir pooperacin kairiosios irdies dilatacijos regresavim, chirurgin gydym Kauno medicinosuniversiteto klinikirdies centre galima pagrstai rekomenduoti pirminiu mitralinio votuvo prolapsu sergan-tiems pacientams, nustaius didesnio laipnio mitralinregurgitacij.

Adresas susirainti: R. Ablonskyt-Ddonien, KMUK Kardiologijos klinika, Eiveni2, 50009 KaunasEl. patas: [email protected]

Received 29 December 2004, accepted 12 April 2005

Straipsnis gautas 2004 12 29, priimtas 2005 04 12


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