What is the management approach for a patient with mitral valve prolapse?

Management of Mitral Valve Prolapse

The management of mitral valve prolapse (MVP) should be guided by symptom status, severity of mitral regurgitation (MR), left ventricular function, and presence of complications, with mitral valve repair strongly preferred over replacement when intervention is indicated. 1

Diagnosis and Assessment

• Echocardiographic Evaluation:

  • Two-dimensional and Doppler echocardiography is essential for diagnosis 2
  • Diagnostic criteria: valve prolapse ≥2 mm above mitral annulus in long-axis parasternal view, leaflet thickness ≥5 mm 2
  • Assess severity of MR using multiple parameters: regurgitant volume, regurgitant fraction, effective regurgitant orifice area (EROA), vena contracta width 1

• Staging of Mitral Regurgitation:

  • Stage A: At risk of MR (mild prolapse with normal coaptation)
  • Stage B: Progressive MR (severe prolapse but regurgitant volume <60 mL)
  • Stage C: Asymptomatic severe MR (regurgitant volume ≥60 mL)
    • C1: LVEF >60% and LVESD <40 mm
    • C2: LVEF ≤60% and LVESD ≥40 mm
  • Stage D: Symptomatic severe MR 1

Management Approach

1. Asymptomatic Patients with No/Mild MR (Stages A and B)

• Clinical follow-up every 3-5 years 2
• Reassurance about benign prognosis 2
• Endocarditis prophylaxis is not routinely recommended unless there is a history of endocarditis 2
• Regular exercise and normal lifestyle should be encouraged 2

2. Asymptomatic Patients with Severe MR (Stage C)

• C1 (preserved LV function):

  • Close monitoring with clinical evaluation and echocardiography every 6-12 months 1
  • Consider early mitral valve repair if:
    • High likelihood of successful repair (>95%)
    • Low operative risk (<1%)
    • Performed at a Heart Valve Center of Excellence 1

• C2 (early LV dysfunction):

  • Mitral valve surgery is recommended (Class I recommendation) 1
  • Repair strongly preferred over replacement 1

3. Symptomatic Patients with Severe MR (Stage D)

• Mitral valve surgery is strongly recommended (Class I recommendation) 1
• Repair is preferred over replacement when feasible 1
• If repair is not feasible, mitral valve replacement with preservation of the subvalvular apparatus is preferred 1

4. Medical Therapy

• No specific medical therapy is indicated for asymptomatic patients with normal LV function 1
• Vasodilator therapy is not indicated for normotensive asymptomatic patients with chronic primary MR and normal LV function (Class III: No Benefit) 1
• Medical therapy for systolic dysfunction is reasonable in symptomatic patients with chronic primary MR and LVEF <60% in whom surgery is not contemplated 1
• Beta blockers may help manage tachyarrhythmias and increased adrenergic symptoms 2

5. Management of Complications

• Atrial fibrillation:

  • Anticoagulation with warfarin for patients with MVP and AF who are >65 years, have hypertension, MR murmur, or history of heart failure 2

• Cerebral ischemic events:

  • Aspirin therapy (75-325 mg daily) for patients with MVP who experience cerebral TIAs 2

• Ventricular arrhythmias:

  • Evaluation for high-risk features
  • Consider ICD therapy for sustained ventricular tachyarrhythmias 2

Surgical Considerations

• Repair is strongly preferred over replacement when feasible 1
• Degenerative MR due to segmental valve prolapse can usually be repaired with a low risk of reoperation 1
• Repair success is highly dependent on:
  • Valve anatomy
  • Surgical expertise
  • Center experience 1
• Patients with complex repair should undergo surgery in experienced repair centers with high repair rates and low operative mortality 1

Follow-up Recommendations

• Asymptomatic patients with mild MR: Clinical evaluation every 3-5 years 2
• Asymptomatic patients with moderate MR: Annual clinical evaluation with echocardiography every 1-2 years 1
• Asymptomatic patients with severe MR: Clinical evaluation every 6 months, echocardiography every 6-12 months 1
• Post-repair/replacement: Initial evaluation at 30 days, then annually if stable 1

Common Pitfalls to Avoid

1. Delaying surgery until symptoms develop - This can lead to irreversible LV dysfunction; surgery should be considered when LVEF approaches 60% or LVESD approaches 40 mm 1

2. Overlooking rapid progression - Patients may remain asymptomatic for decades but deteriorate rapidly once symptoms develop, often requiring surgery within a year 3

3. Missing high-risk features - Leaflet thickness ≥5 mm, moderate-severe MR, LV dysfunction, left atrial enlargement, and flail leaflet are important risk factors 2

4. Inappropriate anticoagulation - Only use in patients with appropriate indications to avoid unnecessary bleeding risks 2