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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
Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius
Medicina (Kaunas) 2005; 41(4)
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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
Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius
Medicina (Kaunas) 2005; 41(4)
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