What is the management approach for symptoms in mitral valve prolapse?

Management of Symptoms in Mitral Valve Prolapse

The management of symptoms in mitral valve prolapse (MVP) should be stratified based on symptom severity, presence of mitral regurgitation (MR), and left ventricular function, with asymptomatic patients with mild MVP requiring only regular monitoring, while those with severe MVP and significant MR should be referred for surgical intervention, particularly valve repair when feasible. 1

Assessment and Classification

• MVP should be classified based on severity: Stage A (mild MVP with normal coaptation and no MR), Stage B (progressive MVP with mild-to-moderate MR), Stage C (severe MVP with loss of coaptation or flail leaflet and severe MR), and Stage D (symptomatic severe MVP with severe MR) 2
• Echocardiography is essential for diagnosis, assessing valve morphology, determining MR severity, and evaluating left ventricular size and function 3, 1
• Quantitative parameters should be used to assess MR severity, with severe primary MR defined as effective regurgitant orifice area ≥0.4 cm² and regurgitant volume ≥60 mL 1

Management Algorithm

Asymptomatic Patients

• Patients with mild MVP without MR require reassurance about the benign prognosis and regular clinical follow-up every 12 months with echocardiography every 2 years 1, 4
• For asymptomatic patients with moderate MR, clinical follow-up every 6 months with annual echocardiography is recommended 1
• Surgery should be considered in asymptomatic patients with severe MR if any of the following are present: left ventricular dysfunction (LVEF ≤60% or LVESD ≥40 mm), new onset atrial fibrillation, or pulmonary hypertension 3, 1

Symptomatic Patients

• For symptomatic patients with mild MVP without significant MR, reassurance and management of symptoms is the primary approach 3, 4
• Beta-blockers are the first-line therapy for symptomatic patients with palpitations, chest pain, or other symptoms that cannot be explained by mitral valve abnormality alone 5, 6
• Mitral valve surgery is strongly recommended for symptomatic patients with chronic severe primary MR (stage D) and LVEF greater than 30% 3, 1

Medical Therapy

• There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 1
• Beta-blockers are beneficial for managing symptoms such as palpitations, chest pain, and anxiety in MVP syndrome 5, 6
• ACE inhibitors should be used in patients with advanced MR and severe symptoms who are not surgical candidates 1
• For patients with MVP and atrial fibrillation, anticoagulation therapy is recommended based on age and risk factors:
  • Warfarin therapy is recommended for patients aged >65 or those with hypertension, MR murmur, or history of heart failure 3
  • Aspirin therapy (75-325 mg daily) is recommended for patients <65 years without MR, hypertension, or heart failure 3

Surgical Management

• Mitral valve repair is strongly preferred over replacement when technically feasible 3, 1
• Different surgical techniques are recommended based on specific MVP pathology:
  • Nonresection techniques using PTFE neochord reconstruction or chordal transfer for focal leaflet flail or bileaflet prolapse 1
  • Focal triangular resection with annuloplasty ring for focal leaflet flail 1
  • Sliding leaflet valvuloplasty with annuloplasty ring for diffuse posterior leaflet myxomatous disease 1
• Outcomes depend significantly on surgeon experience and center volume, with procedures ideally performed at a Heart Valve Center of Excellence 3, 1
• For patients at high surgical risk, percutaneous edge-to-edge repair may be considered 1

Management of Complications

• Endocarditis prophylaxis is recommended for most patients with a definite diagnosis of MVP, particularly if there is associated MR 3, 4
• For patients with MVP and history of stroke:
  • Warfarin therapy is recommended for patients with MR, atrial fibrillation, or left atrial thrombus 3
  • Warfarin therapy is reasonable for patients with echocardiographic evidence of thickened (≥5mm) or redundant valve leaflets 3
  • Aspirin therapy is reasonable for patients without MR, atrial fibrillation, left atrial thrombus, or valve thickening 3
• For patients with MVP and ventricular arrhythmias, beta-blockers are the primary treatment 5, 6

Follow-up Protocol

• Asymptomatic patients with moderate MR should have yearly clinical follow-up with echocardiography every 2 years 1
• Asymptomatic patients with severe MR should have 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, a baseline ECG, X-ray, and echocardiography should be established for future comparison 1

Common Pitfalls and Caveats

• Delaying surgical repair until symptoms develop or left ventricular dysfunction occurs can lead to worse outcomes 1, 7
• Vasodilators may increase mitral valve prolapse and worsen MR by decreasing LV size and mitral closing force 3
• Individuals with thick mitral leaflets and mitral systolic murmur are at higher risk of developing complications and should be monitored more closely 8
• Echocardiographic assessment can overestimate or underestimate MR severity due to various factors such as high blood pressure or left atrial pressures 1