What is the treatment approach for mitral valve prolapse?

Treatment of Mitral Valve Prolapse

Treatment for mitral valve prolapse should be stratified by severity: asymptomatic patients with mild disease require only surveillance, while those with severe mitral regurgitation need surgical intervention, with mitral valve repair strongly preferred over replacement. 1

Risk Stratification and Surveillance

The foundation of MVP management begins with proper staging:

• Stage A (mild MVP): Normal coaptation without mitral regurgitation requires clinical follow-up every 12 months with echocardiography every 2 years 1, 2
• Stage B (progressive MVP): Mild-to-moderate MR necessitates clinical follow-up every 6 months with annual echocardiography 1, 2
• Stage C (severe MVP): Loss of coaptation or flail leaflet with severe MR requires clinical evaluation every 6 months with annual echocardiography 1, 2
• Stage D (symptomatic severe MVP): Severe MR with symptoms mandates immediate surgical evaluation 2

Surgical Indications

Surgery is the definitive treatment for specific high-risk scenarios:

Symptomatic Patients

• Mitral valve surgery is strongly recommended for symptomatic patients with chronic severe primary MR (Stage D) and LVEF >30% 2
• Surgery should not be delayed until symptoms develop, as earlier intervention leads to improved survival and functional outcomes 1

Asymptomatic Patients

Surgery should be considered in asymptomatic patients with severe MR if any of the following are present 1, 2:

• Left ventricular dysfunction (LVEF ≤60% or LVESD ≥40 mm)
• New onset atrial fibrillation
• Pulmonary hypertension (systolic PA pressure >70 mmHg)

Surgical Technique Selection

Mitral valve repair is strongly preferred over replacement when technically feasible, as it provides improved very long-term survival 1, 2, 3. The specific repair technique depends on the pathology 1, 2:

• Focal posterior leaflet flail: Focal triangular resection with annuloplasty ring
• Focal anterior leaflet or bileaflet prolapse: Nonresection techniques using PTFE neochord reconstruction or chordal transfer with annuloplasty ring
• Diffuse posterior leaflet myxomatous disease: Sliding leaflet valvuloplasty with annuloplasty ring

Critical caveat: Outcomes depend significantly on surgeon experience and center volume, with procedures ideally performed at a Heart Valve Center of Excellence 2. Repair of anterior leaflet prolapse has higher reoperation rates (28% at 15 years) compared to posterior leaflet repair (11% at 15 years), though survival remains superior to replacement 3.

Medical Management

There is no evidence supporting vasodilators, including ACE inhibitors, in chronic MR without heart failure 1, 2. Medical therapy is reserved for specific scenarios:

Heart Failure Management

• ACE inhibitors should be used in patients with advanced MR and severe symptoms who are not surgical candidates 1, 2
• Beta-blockers and spironolactone should be considered for heart failure management 1

Anticoagulation

Warfarin therapy (target INR 2-3) is recommended for 1, 2:

• Permanent or paroxysmal atrial fibrillation
• History of systemic embolism
• Evidence of left atrial thrombus
• Patients >65 years with hypertension, MR murmur, or history of heart failure

Arrhythmia Management

• Beta-blockers are the primary treatment for frequent ventricular extrasystoles (>30/hour), ventricular tachycardia, or ventricular fibrillation 4
• Prophylactic beta-blockers may be considered for patients with history of arrhythmias 5

Endocarditis Prophylaxis

Endocarditis prophylaxis is recommended for most patients with definite MVP, particularly if there is associated MR 2. This is critical given that MVP is complicated by infectious endocarditis in 2.9% of cases 4.

High-Risk Surgical Alternatives

For patients at high surgical risk, percutaneous edge-to-edge repair may be considered 1, 2. However, this should be reserved for those who cannot tolerate traditional surgery, as repair provides superior long-term outcomes 3.

Common Pitfalls

• Underestimating MR severity: Echocardiographic assessment can underestimate severity in late-systolic prolapse, where regurgitation occurs only in very late systole 6. Physical examination showing a very late soft systolic murmur with no diastolic filling sound and clear lungs suggests only mild-to-moderate MR despite potentially misleading echo calculations 6
• Delaying surgery: Waiting until symptoms develop or left ventricular dysfunction occurs worsens outcomes 1
• Overestimating surgical risk: The overall prognosis of MVP is excellent, but complications including severe MR occur disproportionately in older men (5% require surgery) versus women (1.5% require surgery) 7