What is the initial approach to managing anterior mitral valve prolapse?

Management of Anterior Mitral Valve Prolapse

For isolated anterior mitral valve prolapse, nonresection techniques using either PTFE neochord reconstruction or ipsilateral chordal transfer from secondary to primary position, combined with annuloplasty ring, is the recommended initial approach. 1

Initial Assessment and Classification

• Anterior mitral valve prolapse represents a specific subtype of primary mitral regurgitation (MR) with Carpentier type II motion, requiring careful evaluation of valve anatomy and regurgitation severity 1, 2
• Comprehensive echocardiography is essential to assess the specific pathology, including the extent of prolapse, presence of flail segments, and degree of mitral regurgitation 2
• Severity assessment should include quantitative parameters such as effective regurgitant orifice area (EROA) and regurgitant volume, with severe primary MR defined as EROA ≥0.4 cm² and regurgitant volume ≥60 mL 2

Medical Management for Asymptomatic Patients

• Regular clinical follow-up is recommended based on MR severity:
  • Mild MR: Clinical follow-up every 12 months with echocardiography every 2 years 2
  • Moderate MR: Clinical follow-up every 6 months with annual echocardiography 2
• There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 2
• Beta-blockers may be beneficial for symptomatic patients with palpitations or arrhythmias 3
• Antibiotic prophylaxis should be considered for patients with a pansystolic or end-systolic murmur prior to dental procedures or surgery to prevent infective endocarditis 4

Surgical Intervention Criteria

• Surgery is recommended for symptomatic patients with severe MR due to anterior mitral valve prolapse 1, 2
• Surgical intervention is also recommended for asymptomatic patients with severe MR if any of the following are present:
  • Left ventricular dysfunction (LVEF ≤60%)
  • Left ventricular end-systolic dimension ≥40 mm
  • New onset atrial fibrillation
  • Pulmonary hypertension 1, 2

Surgical Techniques for Anterior Mitral Valve Prolapse

• Nonresection techniques are the preferred initial approach for isolated anterior leaflet prolapse: 1
  • PTFE neochord reconstruction
  • Ipsilateral chordal transfer from secondary to primary position
  • Always combined with annuloplasty ring
• Focal triangular resection with annuloplasty ring may rarely be used for focal anterior leaflet defects 1
• The "edge-to-edge" technique has shown promising results for anterior leaflet repair, with studies reporting 85.4% freedom from reoperation at 8 years 5

Repair vs. Replacement Considerations

• Mitral valve repair is strongly preferred over replacement when technically feasible for anterior leaflet prolapse 1, 2
• Long-term survival is significantly better with repair compared to replacement for anterior leaflet prolapse (42% vs. 31% at 14 years) 6
• However, repair of anterior leaflet prolapse is technically more challenging than posterior leaflet repair, with higher reoperation rates (28% vs. 11% at 15 years) 6
• Patients with severe anterior leaflet prolapse should be referred to experienced mitral valve surgeons at high-volume centers 1

Important Caveats and Pitfalls

• Anterior leaflet repair is technically more challenging than posterior leaflet repair, requiring specific surgical expertise 1
• The most important predictor of long-term repair failure is the presence of moderate or greater residual MR at the time of the index operation 1
• Surgical repair should not be delayed until symptoms develop or left ventricular dysfunction occurs, as earlier intervention leads to improved outcomes 2
• Repair techniques have improved over time, with reoperation rates for anterior leaflet prolapse decreasing from 24% to 10% at 10 years between the 1980s and 1990s 6

Post-Surgical Follow-up

• After mitral valve repair, a baseline echocardiogram should be established for future comparison 2
• Regular clinical and echocardiographic follow-up is essential to monitor for recurrent MR or other complications 2
• Anticoagulation therapy may be required for patients who develop atrial fibrillation 1, 2