Mitral Valve Prolapse

Cardiovascular

Clinicals - History

Fact Explanation
Cardiovascular symptoms: exercise intolerance, fatigue, sustained heart rate, syncope, dizziness, light headedness, balance problems Cardiovascular neuropathy is a result of damage to vagal and sympathetic nerves.
The pathogenesis is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death
Cardiovascular symptoms: exercise intolerance, fatigue, sustained heart rate, syncope, dizziness, light headedness, balance problems
Cardiovascular neuropathy is a result of damage to vagal and sympathetic nerves.
The pathogenesis is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death
Gastrointestinal symptoms: dysphagia, diarrhea, constipation, loss of bowel control Dysphagia occurs due to reduced contraction amplitudes of the tubular esophagus
Diabetic diarrhea is a result of increased or uncoordinated transit time in the small intestine, bacterial overgrowth, or increased intestinal secretions.
Constipation occurs due to decreased transit time in the large intestine. Loss of bowel control is due to reduced threshold of conscious rectal sensation,decreased resting anal sphincter pressure.
Gastrointestinal symptoms: dysphagia, diarrhea, constipation, loss of bowel control
Dysphagia occurs due to reduced contraction amplitudes of the tubular esophagus
Diabetic diarrhea is a result of increased or uncoordinated transit time in the small intestine, bacterial overgrowth, or increased intestinal secretions.
Constipation occurs due to decreased transit time in the large intestine. Loss of bowel control is due to reduced threshold of conscious rectal sensation,decreased resting anal sphincter pressure.
Genitourinary symptoms: loss of bladder control, urinary tract infection, urinary frequency or dribbling, erectile dysfunction, loss of libido, dyspareunia, vaginal dryness Loss of bladder control occurs by the Inability to sense a full bladder and detrusor muscle hypoactivity.These conditions can progress to overflow incontinence and urinary tract infections.Hyperglycemia alone also can cause increased urine production and incontinence. loss of libido,dyspareunia,vaginal dryness is a result of pelvic plexus neuropathy
Erectile dysfunction in diabetes is multifactorial, including neuropathy,hypogonadism, vascular disease, metabolic control and psychogenic factors.
Diabetic men have impaired neurogenic and endothelium mediated relaxation of penile smooth muscles
Genitourinary symptoms: loss of bladder control, urinary tract infection, urinary frequency or dribbling, erectile dysfunction, loss of libido, dyspareunia, vaginal dryness
Loss of bladder control occurs by the Inability to sense a full bladder and detrusor muscle hypoactivity.These conditions can progress to overflow incontinence and urinary tract infections.Hyperglycemia alone also can cause increased urine production and incontinence. loss of libido,dyspareunia,vaginal dryness is a result of pelvic plexus neuropathy
Erectile dysfunction in diabetes is multifactorial, including neuropathy,hypogonadism, vascular disease, metabolic control and psychogenic factors.
Diabetic men have impaired neurogenic and endothelium mediated relaxation of penile smooth muscles
Sudomotor symptoms: pruritus, dry skin, limb hair loss,anhidrosis,heat intolerance,gustatory sweating Dry skin,hair loss- Poor peripheral circulation (neuronal input to the peripheral vasculature is decreased or absent)
Gustatory sweating-Loss of autonomic supply to auriculotemporal nerve.
Sudomotor symptoms: pruritus, dry skin, limb hair loss,anhidrosis,heat intolerance,gustatory sweating
Dry skin,hair loss- Poor peripheral circulation (neuronal input to the peripheral vasculature is decreased or absent)
Gustatory sweating-Loss of autonomic supply to auriculotemporal nerve.
Endocrine symptoms: hypoglycemic unawareness Impaired catecholamine release prevents the warning signs of hypoglcemia. Endocrine symptoms: hypoglycemic unawareness
Impaired catecholamine release prevents the warning signs of hypoglcemia.
Eyes: diplopia Loss of autonomic supply to ocular muscles. Eyes: diplopia
Loss of autonomic supply to ocular muscles.
Dizziness while standing up from seated position Orthostatic hypotension (systolic blood pressure drop of at least 20 mm Hg or diastolic blood pressure drop of at least 10 mm Hg when standing up.)
Vasomotor neuropathy frequently causes orthostatic hypotension by affecting the splanchnic and peripheral vascular beds.
Dizziness while standing up from seated position
Orthostatic hypotension (systolic blood pressure drop of at least 20 mm Hg or diastolic blood pressure drop of at least 10 mm Hg when standing up.)
Vasomotor neuropathy frequently causes orthostatic hypotension by affecting the splanchnic and peripheral vascular beds.
Poor diabetic control , long duration of diabetes, History of hypertension, dyslipidemia Risk factors for the development of diabetic autonomic neuropathy as damage to the nerves will be increased with time due to long exposure to hyperglycemia.
The risk is also high in patients who are having other comorbidities which has macrovascular events such as hypertension and dyslipidemia
Poor diabetic control , long duration of diabetes, History of hypertension, dyslipidemia
Risk factors for the development of diabetic autonomic neuropathy as damage to the nerves will be increased with time due to long exposure to hyperglycemia.
The risk is also high in patients who are having other comorbidities which has macrovascular events such as hypertension and dyslipidemia

Clinicals - Examination

Fact Explanation
Thoracic skeletal abnormalities: the most common are scoliosis, pectus excavatum, straightened thoracic spine and narrowed anteroposterior diameter of the chest Due to connective tissue disorders.Thoracic skeletal abnormalities are commonly associated with mitral valve prolapse (MVP) Thoracic skeletal abnormalities: the most common are scoliosis, pectus excavatum, straightened thoracic spine and narrowed anteroposterior diameter of the chest
Due to connective tissue disorders.Thoracic skeletal abnormalities are commonly associated with mitral valve prolapse (MVP)
Stigmata, such as arachnodactyly, that are more typical of Marfan syndrome Primary MVP due to Marfan syndrome Stigmata, such as arachnodactyly, that are more typical of Marfan syndrome
Primary MVP due to Marfan syndrome
Heart murmur Midsystolic click, a high-pitched sound of short duration.The midsystolic click is frequently followed by a late systolic murmur, usually medium to high pitched and loudest at the apex
Maneuvers that cause the click or murmur to occur earlier in systole include standing from the supine position, performing a sub-maximal isometric handgrip exercise, straining during the Valsalva maneuver and inhaling amyl nitrite. Maneuvers that cause the click and murmur to move toward the second heart sound include squatting from the upright position
Heart murmur
Midsystolic click, a high-pitched sound of short duration.The midsystolic click is frequently followed by a late systolic murmur, usually medium to high pitched and loudest at the apex
Maneuvers that cause the click or murmur to occur earlier in systole include standing from the supine position, performing a sub-maximal isometric handgrip exercise, straining during the Valsalva maneuver and inhaling amyl nitrite. Maneuvers that cause the click and murmur to move toward the second heart sound include squatting from the upright position
Tachycardia May be present sometimes.Paroxysmal supraventricular tachycardia is the most common sustained tachycardia Tachycardia
May be present sometimes.Paroxysmal supraventricular tachycardia is the most common sustained tachycardia

Investigations - Diagnosis

Fact Explanation
Electrocardiogram The most common abnormality is the presence of ST-T wave depression or T-wave inversion in the inferior leads (II, III and aVF) Electrocardiogram
The most common abnormality is the presence of ST-T wave depression or T-wave inversion in the inferior leads (II, III and aVF)
Echocardiography Two-dimensional and Doppler echocardiography is the most useful noninvasive test for diagnosing mitral valve prolapse (MVP). The M-mode echocardiographic definition of MVP includes posterior displacement of one or both leaflets 2 mm or more during late systole or holosystolic posterior displacement greater than 3 mm Echocardiography
Two-dimensional and Doppler echocardiography is the most useful noninvasive test for diagnosing mitral valve prolapse (MVP). The M-mode echocardiographic definition of MVP includes posterior displacement of one or both leaflets 2 mm or more during late systole or holosystolic posterior displacement greater than 3 mm
Chest X ray Usually show normal cardiopulmonary findings. The skeletal abnormalities,such as pectus excavatum are often seen Chest X ray
Usually show normal cardiopulmonary findings. The skeletal abnormalities,such as pectus excavatum are often seen

Investigations - Management

Fact Explanation
Echocardiogram To assess the severity with time (eg: left ventricular function-todetect cardiac failure which is a complication of mitral valve prolapse)
Signs of mitral regurgitation appears in some patients, but the patients remained clinically asymptomatic.
Also to detect features of infective endocarditis (vegetations), which is a complication of mitral valve prolapse (MVP)
Echocardiogram
To assess the severity with time (eg: left ventricular function-todetect cardiac failure which is a complication of mitral valve prolapse)
Signs of mitral regurgitation appears in some patients, but the patients remained clinically asymptomatic.
Also to detect features of infective endocarditis (vegetations), which is a complication of mitral valve prolapse (MVP)
Elactrocardiogram To identify arrhythmia which is a complication of mitral valve prolapse.Ventricular tachycardia may developed.Sudden death, is most likely due to ventricular fibrillation Elactrocardiogram
To identify arrhythmia which is a complication of mitral valve prolapse.Ventricular tachycardia may developed.Sudden death, is most likely due to ventricular fibrillation
Clinical evaluation Asymptomatic patients with MVP and no significant mitral regurgitation (MR) can be evaluated clinically every 3 to 5 years.Patients who have high-risk characteristics, including those with moderate to severe MR, should be followed once a year Clinical evaluation
Asymptomatic patients with MVP and no significant mitral regurgitation (MR) can be evaluated clinically every 3 to 5 years.Patients who have high-risk characteristics, including those with moderate to severe MR, should be followed once a year
Full blood count To assess general fitness, fitness for surgery if required Full blood count
To assess general fitness, fitness for surgery if required
Electrocardiogram To identify coexisting ischemic changes Electrocardiogram
To identify coexisting ischemic changes
Fasting blood sugar It is advised to control other co morbid conditions such as diabetes.Also to assess fitness for surgery if required Fasting blood sugar
It is advised to control other co morbid conditions such as diabetes.Also to assess fitness for surgery if required
Lipid profile It is advised to control other co morbid conditions such as dyslipidemia.Also to assess fitness for surgery if required Lipid profile
It is advised to control other co morbid conditions such as dyslipidemia.Also to assess fitness for surgery if required
Echocardiogram Used to grade mitral valve prolapse (MVP)
1. Diagnosis, assessment of hemodynamic severity of MR, leaflet morphology, and ventricular compensation in patients with physical signs of MVP- class I
2. To exclude MVP in patients who have been given the diagnosis when there is no clinical evidence to support the diagnosis-class I
3. To exclude MVP in patients with first-degree relatives with known myxomatous valve disease- class IIa
4. Risk stratification in patients with physical signs of MVP or known MVP- class IIa
5. To exclude MVP in patients in the absence of physical findings suggestive of MVP or a positive family history- class III
6. Routine repetition of echocardiography in patients with MVP with mild or no regurgitation and no changes in clinical signs or symptoms- class III
Echocardiogram
Used to grade mitral valve prolapse (MVP)
1. Diagnosis, assessment of hemodynamic severity of MR, leaflet morphology, and ventricular compensation in patients with physical signs of MVP- class I
2. To exclude MVP in patients who have been given the diagnosis when there is no clinical evidence to support the diagnosis-class I
3. To exclude MVP in patients with first-degree relatives with known myxomatous valve disease- class IIa
4. Risk stratification in patients with physical signs of MVP or known MVP- class IIa
5. To exclude MVP in patients in the absence of physical findings suggestive of MVP or a positive family history- class III
6. Routine repetition of echocardiography in patients with MVP with mild or no regurgitation and no changes in clinical signs or symptoms- class III
Chest X ray To look for the evidence of skeletal abnormalities,such as pectus excavatum which is associated with primary mitral valve prolapse Chest X ray
To look for the evidence of skeletal abnormalities,such as pectus excavatum which is associated with primary mitral valve prolapse

Management - Supportive

Fact Explanation
Regular exercise A normal lifestyle and regular exercise are encouraged for most patients with mitral valve prolapse (MVP), especially those who are asymptomatic Regular exercise
A normal lifestyle and regular exercise are encouraged for most patients with mitral valve prolapse (MVP), especially those who are asymptomatic
Restriction from competitive sports Recommended when moderate left ventricular (LV) enlargement, LV dysfunction, uncontrolled tachyarrhythmias, long QT interval, unexplained syncope Restriction from competitive sports
Recommended when moderate left ventricular (LV) enlargement, LV dysfunction, uncontrolled tachyarrhythmias, long QT interval, unexplained syncope
Patient education Reassurance- most patients are asymptomatic and not at high risk for serious consequences
A familial occurrence of MVP should be explained to the patient and is particularly important in those with associated disease who are at greater risk for complications. There is no contraindication to pregnancy based on the diagnosis of MVP alone
Educate about the comlications-
Atrial fibrillation and other arrhythmias, Congestive heart failure,
Pulmonaryhypertension,
Ruptured mitral valve chordae,
Infective endocarditis,
Central nervous system embolic events
Patient education
Reassurance- most patients are asymptomatic and not at high risk for serious consequences
A familial occurrence of MVP should be explained to the patient and is particularly important in those with associated disease who are at greater risk for complications. There is no contraindication to pregnancy based on the diagnosis of MVP alone
Educate about the comlications-
Atrial fibrillation and other arrhythmias, Congestive heart failure,
Pulmonaryhypertension,
Ruptured mitral valve chordae,
Infective endocarditis,
Central nervous system embolic events
Follwed up with clinical evaluation Asymptomatic patients with MVP and no significant mitral valve prolapse (MR) can be evaluated clinically every 3 to 5 years.Patients who have high-risk characteristics, including those with moderate to severe MR, should be followed once a year Follwed up with clinical evaluation
Asymptomatic patients with MVP and no significant mitral valve prolapse (MR) can be evaluated clinically every 3 to 5 years.Patients who have high-risk characteristics, including those with moderate to severe MR, should be followed once a year
Antibiotic prophylaxis Antibiotic prophylaxis for the prevention of infective endocarditis during procedures that carry a risk for bacteremia is recommended in most patients with a definite diagnosis of MVP Antibiotic prophylaxis
Antibiotic prophylaxis for the prevention of infective endocarditis during procedures that carry a risk for bacteremia is recommended in most patients with a definite diagnosis of MVP

Management - Specific

Fact Explanation
Beta blockers Patients with Mitral valve prolapse (MVP) and palpitations associated with mild tachyarrhythmias or increased adrenergic symptoms and those with chest pain, anxiety or fatigue often respond to therapy with beta blockers Beta blockers
Patients with Mitral valve prolapse (MVP) and palpitations associated with mild tachyarrhythmias or increased adrenergic symptoms and those with chest pain, anxiety or fatigue often respond to therapy with beta blockers
Daily aspirin therapy (80 to 325 mg per day) Recommended for patients with MVP who have a history of focal neurologic events and who are in sinus rhythm but have no atrial thrombi. Such patients should also avoid smoking cigarettes and taking oral contraceptives Daily aspirin therapy (80 to 325 mg per day)
Recommended for patients with MVP who have a history of focal neurologic events and who are in sinus rhythm but have no atrial thrombi. Such patients should also avoid smoking cigarettes and taking oral contraceptives
Long-term anticoagulation therapy with warfarin Recommended for patients with MVP who have had a stroke and those who have recurrent transient ischemic attacks while on aspirin therapy (the International Normalized Ratio [INR] should be maintained between 2 and 3 Long-term anticoagulation therapy with warfarin
Recommended for patients with MVP who have had a stroke and those who have recurrent transient ischemic attacks while on aspirin therapy (the International Normalized Ratio [INR] should be maintained between 2 and 3
Restriction from competitive sports Recommended when moderate left ventricular (LV) enlargement, LV dysfunction, uncontrolled tachyarrhythmias, long QT interval, unexplained syncope Restriction from competitive sports
Recommended when moderate left ventricular (LV) enlargement, LV dysfunction, uncontrolled tachyarrhythmias, long QT interval, unexplained syncope
Surgical considerations Management of MVP may require valve surgery, particularly in those patients who develop a flail mitral leaflet due to rupture of chordae tendineae or their marked elongation,Most such valves can be repaired successfully by surgeons experienced in mitral valve repair, especially when the posterior leaflet of the mitral valve is predominantly affected
A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques
Surgical considerations
Management of MVP may require valve surgery, particularly in those patients who develop a flail mitral leaflet due to rupture of chordae tendineae or their marked elongation,Most such valves can be repaired successfully by surgeons experienced in mitral valve repair, especially when the posterior leaflet of the mitral valve is predominantly affected
A minimally invasive approach allows repair of almost all degenerative valves with good short-term outcomes in a tertiary referral center, when using proven and efficient surgical techniques
Antibiotic prophylaxis Antibiotic prophylaxis for the prevention of infective endocarditis during procedures that carry a risk for bacteremia is recommended in most patients with a definite diagnosis of MVP Antibiotic prophylaxis
Antibiotic prophylaxis for the prevention of infective endocarditis during procedures that carry a risk for bacteremia is recommended in most patients with a definite diagnosis of MVP

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