What is the management strategy for anterior mitral valve prolapse?

Management of Anterior Mitral Valve Prolapse

Surgical intervention with nonresection techniques using PTFE neochord reconstruction or chordal transfer, combined with annuloplasty ring, is the preferred approach for anterior mitral valve prolapse with significant mitral regurgitation. 1, 2

Assessment and Classification

• Comprehensive echocardiography is essential to evaluate the extent of anterior leaflet prolapse, presence of flail segments, and degree of mitral regurgitation 1
• 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 1, 3
• Mitral regurgitation should be classified as primary (structural abnormality of valve leaflets/chordae) or secondary (left ventricular geometry alterations) 3

Management Strategy Based on Severity

• Asymptomatic patients with mild MVP require only regular monitoring with clinical follow-up every 12 months and echocardiography every 2 years 3
• Patients with moderate MR should have clinical follow-up every 6 months with annual echocardiography 3
• Asymptomatic patients with severe MR should have clinical evaluation every 6 months with annual echocardiography 3, 4

Surgical Intervention Criteria

• Surgery is recommended for symptomatic patients with severe MR due to anterior mitral valve prolapse 3, 1
• Surgery should be considered in 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 3, 1

Surgical Techniques for Anterior Mitral Valve Prolapse

• Nonresection techniques are the preferred approach for isolated anterior leaflet prolapse 1, 2:
  • PTFE neochord reconstruction
  • Ipsilateral chordal transfer from secondary to primary position
  • Annuloplasty ring
• Alternative techniques include:
  • Chordal shortening 5
  • Edge-to-edge repair (Alfieri stitch) in selected cases 6
  • Focal triangular resection with annuloplasty ring (rarely used for focal anterior leaflet defects) 2

Repair vs. Replacement Considerations

• Mitral valve repair is strongly preferred over replacement when technically feasible due to better long-term survival and lower reoperation rates 3, 1
• Patients with anterior leaflet prolapse should be referred to experienced mitral valve surgeons at high-volume centers 1, 7
• Contemporary surgical techniques can achieve repair rates approaching 100% for anterior leaflet prolapse 7

Medical Management

• There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 3
• ACE inhibitors should be used in patients with advanced MR and severe symptoms who are not surgical candidates 3
• Beta-blockers and spironolactone should be considered as appropriate for heart failure management 3
• Anticoagulant therapy with target INR between 2-3 is recommended for patients with permanent or paroxysmal atrial fibrillation 3

Post-Surgical Follow-up

• A baseline ECG, X-ray, and echocardiography should be established after repair/replacement for future comparison 3
• Regular clinical and echocardiographic follow-up is essential to monitor for recurrent MR 1
• Anticoagulation therapy may be required for patients who develop atrial fibrillation 1

Common Pitfalls and Caveats

• Delaying surgical intervention until symptoms become severe or left ventricular dysfunction occurs leads to worse outcomes 3, 4
• Echocardiographic assessment can overestimate or underestimate mitral regurgitation severity due to various factors, such as high blood pressure or left atrial pressures 3
• Failing to recognize the dynamic nature of MR can lead to inappropriate management decisions 4
• Endocarditis prophylaxis is appropriate for patients with mitral regurgitation 8