What is the management approach for patients with mitral valve prolapse?

Management of Mitral Valve Prolapse

Management of mitral valve prolapse is stratified by disease severity and presence of mitral regurgitation, with asymptomatic patients requiring only surveillance while those with severe MR and symptoms, LV dysfunction (LVEF ≤60% or LVESD ≥40mm), new atrial fibrillation, or pulmonary hypertension should undergo mitral valve repair. 1, 2

Initial Assessment and Staging

The cornerstone of MVP management begins with comprehensive echocardiographic evaluation to determine disease stage and guide treatment decisions. 1, 3

Stage A (At Risk): Mild MVP with normal coaptation, no MR jet or small central jet <20% LA, no chamber enlargement, and no symptoms. 1

Stage B (Progressive): Severe MVP with normal coaptation, central jet MR 20-40% LA or late systolic eccentric jet, vena contracta <0.7 cm, regurgitant volume <60 mL, mild LA enlargement, and no symptoms. 1

Stage C (Asymptomatic Severe): Severe MVP with loss of coaptation or flail leaflet, central jet MR >40% LA or holosystolic eccentric jet, vena contracta ≥0.7 cm, regurgitant volume ≥60 mL, moderate-severe LA enlargement, LV enlargement, and no symptoms. This subdivides into C1 (LVEF >60% and LVESD <40mm) and C2 (LVEF ≤60% and LVESD ≥40mm). 1

Stage D (Symptomatic Severe): Same hemodynamic criteria as Stage C but with decreased exercise tolerance or exertional dyspnea. 1

Surveillance Strategy

For Stage A patients: Clinical follow-up every 12 months with echocardiography every 2 years is sufficient given the benign prognosis. 2

For Stage B patients: Clinical follow-up every 6 months with annual echocardiography to monitor for progression to severe MR. 2, 3

For Stage C patients: Clinical evaluation every 6 months with annual echocardiography to detect early LV dysfunction, new atrial fibrillation, or pulmonary hypertension that would trigger surgical referral. 1, 2, 3 Closer monitoring is warranted for borderline values or significant interval changes. 2

The 2014 AHA/ACC guidelines emphasize that symptom onset is itself a negative prognostic event even with preserved LV function, as symptoms reflect changes in LV diastolic function, left atrial compliance, and pulmonary pressures that are not readily captured by imaging alone. 1 Importantly, symptom improvement with diuretics does not change the prognostic significance of symptom onset. 1

Medical Management

There is no role for vasodilators including ACE inhibitors in chronic MR without heart failure. 2, 3 This represents a critical pitfall—these medications do not alter disease progression in asymptomatic patients with preserved LV function. 2

ACE inhibitors should be reserved for patients with advanced MR and severe symptoms who are not surgical candidates. 2, 3 In these patients, beta-blockers and spironolactone should be added as appropriate for heart failure management. 2

For patients who develop atrial fibrillation, anticoagulation with warfarin (target INR 2-3) is recommended for those with permanent or paroxysmal AF, history of systemic embolism, or left atrial thrombus. 2, 3

Surgical Indications

Mitral valve surgery is strongly recommended for all symptomatic patients (Stage D) with chronic severe primary MR and LVEF >30%. 3 Surgery should not be delayed until symptoms develop or LV dysfunction occurs, as earlier intervention leads to improved survival and functional outcomes. 2

For asymptomatic patients with severe MR (Stage C), surgery is recommended when any of the following develop: 1, 2, 3

• LV dysfunction (LVEF ≤60% or LVESD ≥40mm)
• New onset atrial fibrillation
• Pulmonary hypertension (approaching 50 mm Hg)

The rationale for these thresholds is that a "normal" LVEF in MR is approximately 70% due to favorable loading conditions, so decline toward 60% represents early LV dysfunction. 1 Similarly, inability to contract to <40mm at end-systole indicates impaired contractility. 1

Surgical Technique Selection

Mitral valve repair is strongly preferred over replacement when technically feasible. 2, 3 This preference is based on lower operative mortality and avoidance of prosthetic valve complications that accumulate over time. 1

Specific repair techniques should be tailored to the pathology: 2, 3

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

Outcomes depend significantly on surgeon experience and center volume, so procedures should ideally be performed at Heart Valve Centers of Excellence. 3

For patients at high surgical risk, percutaneous edge-to-edge repair may be considered as an alternative. 2, 3

Endocarditis Prophylaxis

Antibiotic prophylaxis is recommended for most patients with definite MVP, particularly those with associated MR or a systolic murmur. 3, 4 This is especially important given that infective endocarditis occurs in 2.9% of MVP patients and represents a major complication. 5

Common Pitfalls

Echocardiographic assessment can underestimate MR severity in late-systolic prolapse where regurgitation occurs only in very late systole—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. 2

Do not delay surgery until symptoms develop or LV dysfunction is advanced, as this worsens long-term outcomes. 2 The presence of symptoms alone warrants surgical consideration even if LV function appears preserved on standard measurements. 1

Avoid routine TEE for surveillance—it is reserved for cases where TTE provides inadequate information about MR severity, mechanism, or LV function, or when assessing valve reparability before surgery. 1