What is the treatment for mitral valve prolapse?

Treatment of Mitral Valve Prolapse

The treatment for mitral valve prolapse (MVP) should be stratified based on severity, with asymptomatic patients with mild MVP requiring only regular monitoring, while those with severe MVP and significant mitral regurgitation (MR) should be referred for surgical intervention, particularly valve repair when feasible. 1

Treatment Strategy Based on MVP Severity

Asymptomatic MVP with No or Mild MR (Stage A)

• Regular clinical follow-up every 12 months with echocardiography every 2 years is recommended 1
• No specific medical therapy is indicated for asymptomatic patients without significant MR 1
• Endocarditis prophylaxis is required for patients with MVP 1

MVP with Moderate MR (Stage B)

• Clinical follow-up every 6 months with annual echocardiography is recommended 1
• Patients should be instructed to promptly report any change in functional status 1
• Beta-blockers may be beneficial for patients with arrhythmias or palpitations 2, 3
• Antiplatelet therapy may be considered for patients with history of transient ischemic events 3

Severe MVP with Significant MR (Stages C and D)

• Surgery is recommended for symptomatic patients with severe MR 1
• Surgery should be considered in asymptomatic patients with severe MR if any of the following are present:
  • Left ventricular dysfunction (LVEF ≤60% and/or end-systolic dimension ≥45 mm) 1
  • New onset atrial fibrillation 1
  • Pulmonary hypertension (systolic pulmonary arterial pressure >50 mmHg at rest) 1
  • Flail leaflet and LVESD ≥40 mm 1

Medical Therapy Options

For MVP Without Heart Failure

• There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 1
• Beta-blockers may be beneficial for:
  • Patients with arrhythmias or palpitations 2, 3, 4
  • Preventing deterioration of left ventricular function in asymptomatic patients with moderate to severe MR 4

For MVP With Heart Failure

• ACE inhibitors have benefit and should be used in patients with advanced MR and severe symptoms who are not surgical candidates 1
• Beta-blockers and spironolactone should be considered as appropriate for heart failure management 1

For MVP With Atrial Fibrillation

• Anticoagulant therapy with target INR between 2-3 is recommended for patients with:
  • Permanent or paroxysmal atrial fibrillation 1
  • History of systemic embolism 1
  • Evidence of left atrial thrombus 1
  • First 3 months following mitral valve repair 1
• Heart rate control is essential if atrial fibrillation occurs 1

Surgical Management

Indications for Surgery

• Symptomatic patients with severe MR 1
• Asymptomatic patients with severe MR and LV dysfunction, atrial fibrillation, or pulmonary hypertension 1
• Early surgery (within 2 months) when guideline indications are met is associated with better outcomes 1

Surgical Approach

• Mitral valve repair is strongly preferred over replacement when technically feasible 1
• Outcomes depend significantly on surgeon experience and center volume 1
• For patients at high surgical risk, percutaneous edge-to-edge repair may be considered 1

Special Considerations

Arrhythmias in MVP

• Frequent ventricular extrasystoles (>30/hour), ventricular tachycardia, and ventricular fibrillation should be treated, primarily with beta-blockers 3
• Surgery may be considered for patients with severe arrhythmias despite adequate medical therapy, even without significant MR, but only after extensive trial of medical therapy 5

Thromboembolic Risk

• Anti-platelet agents are recommended for patients with history of transient ischemic events 3
• Anticoagulants should be considered in recurrent cases 3

Follow-up Protocol

• Asymptomatic patients with moderate MR: yearly clinical follow-up with echocardiography every 2 years 1
• Asymptomatic patients with severe MR: clinical evaluation every 6 months with annual echocardiography 1
• Closer follow-up is needed for patients with borderline values or significant changes since the last visit 1
• Post-repair/replacement: establish baseline ECG, X-ray, and echocardiography for future comparison 1

Pitfalls to Avoid

• Failing to recognize the severity of MVP and associated MR before any procedures 2
• Neglecting to maintain appropriate heart rate control, as excessive bradycardia can worsen MR 2
• Delaying surgery in patients who meet criteria, as this can lead to irreversible LV dysfunction 1
• Using vasodilators in patients with hypertrophic cardiomyopathy or MVP, as they can increase MR severity 4