Management of Mitral Valve Prolapse
Management of mitral valve prolapse should be stratified by disease severity and presence of mitral regurgitation, with asymptomatic patients with mild disease requiring only surveillance, while symptomatic patients or those with severe MR and complications (LV dysfunction, atrial fibrillation, or pulmonary hypertension) should undergo mitral valve repair. 1
Disease Staging and Initial Assessment
The American College of Cardiology and American Heart Association classify MVP into four stages that guide management decisions 1, 2:
- Stage A (Mild MVP): Normal coaptation, no MR or small central jet, no symptoms - requires only surveillance 1
- Stage B (Progressive MVP): Mild-to-moderate MR with normal coaptation - requires regular monitoring 1
- Stage C (Severe MVP): Loss of coaptation or flail leaflet with severe MR (EROA ≥0.4 cm², regurgitant volume ≥60 mL), asymptomatic - surgical consideration based on specific criteria 1, 2
- Stage D (Symptomatic Severe MVP): Same hemodynamic criteria as Stage C but with decreased exercise tolerance or exertional dyspnea - surgery recommended 1, 2
Echocardiography is essential to determine valve morphology, MR severity, left ventricular size and function (LVEF and LVESD), and pulmonary artery pressures 1, 2.
Surveillance Protocol
For asymptomatic patients with mild MR: Clinical follow-up every 12 months with echocardiography every 2 years 1
For asymptomatic patients with moderate MR: Clinical follow-up every 6 months with annual echocardiography 1, 2
For asymptomatic patients with severe MR: Clinical evaluation every 6 months with annual echocardiography 1, 2
Closer follow-up is needed for patients with borderline values or significant changes since the last visit 1.
Surgical Indications
Surgery is mandatory for symptomatic patients (Stage D) with chronic severe primary MR and LVEF >30% 1, 2. The American Heart Association emphasizes that symptom onset is itself a negative prognostic event even with preserved LV function, and symptom improvement with diuretics does not change the prognostic significance 1.
For asymptomatic patients with severe MR (Stage C), surgery is recommended when ANY of the following develop 1, 2:
- Left ventricular dysfunction (LVEF ≤60% or LVESD ≥40 mm)
- New onset atrial fibrillation
- Pulmonary hypertension
Critical pitfall: Do not delay surgery until symptoms develop or LV dysfunction occurs, as earlier intervention leads to improved survival and functional outcomes 1. The presence of symptoms alone warrants surgical consideration even if LV function appears preserved on standard measurements 1.
Surgical Technique Selection
Mitral valve repair is strongly preferred over replacement when technically feasible 1, 2. The American College of Cardiology recommends specific techniques based on pathology 1, 2:
- Focal posterior leaflet flail: Focal triangular resection with annuloplasty ring 1
- Focal leaflet flail or bileaflet prolapse: Nonresection techniques using PTFE neochord reconstruction or chordal transfer with annuloplasty ring 1, 2
- Isolated anterior leaflet prolapse: PTFE neochord reconstruction, ipsilateral chordal transfer, and annuloplasty ring 1
- Diffuse posterior leaflet myxomatous disease: Sliding leaflet valvuloplasty with annuloplasty ring 1
Outcomes depend significantly on surgeon experience and center volume; procedures should ideally be performed at a Heart Valve Center of Excellence 2. For patients at high surgical risk, percutaneous edge-to-edge repair may be considered 1, 2.
Medical Therapy
There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 1, 2. This is a common pitfall to avoid.
ACE inhibitors have benefit and should be used only in patients with advanced MR and severe symptoms who are not surgical candidates 1, 2.
Beta-blockers and spironolactone should be considered as appropriate for heart failure management 1.
For arrhythmias: Beta-blockers are the primary treatment for symptomatic arrhythmias, particularly for frequent ventricular extrasystoles (>30/hour), ventricular tachycardia, or ventricular fibrillation 3, 4.
Anticoagulation Management
For patients with permanent or paroxysmal atrial fibrillation: Anticoagulant therapy with target INR between 2-3 is recommended 1.
For patients with history of stroke 2:
- Warfarin therapy is recommended for patients with MR, atrial fibrillation, or left atrial thrombus
- Aspirin therapy is reasonable for patients without MR, atrial fibrillation, left atrial thrombus, or valve thickening
For patients with atrial fibrillation based on age and risk factors 2:
- Warfarin therapy for patients aged >65 or those with hypertension, MR murmur, or history of heart failure
- Aspirin therapy for patients <65 years without MR, hypertension, or heart failure
Endocarditis Prophylaxis
Endocarditis prophylaxis is recommended for most patients with a definite diagnosis of MVP, particularly if there is associated MR 2. Patients with MVP who have a murmur and/or thickened redundant leaflets on echocardiography should receive antibiotic prophylaxis prior to dental treatment or surgery 2, 3, 5.
Patients with MVP who have neither a murmur nor Doppler evidence of mitral regurgitation may be reassured that their condition is benign and do not require prophylaxis 6.
Post-Surgical Follow-up
After repair or replacement, establish a baseline ECG, chest X-ray, and echocardiography for future comparison 1, 2.
Important Diagnostic Caveat
Echocardiographic assessment can underestimate the severity of mitral regurgitation in late-systolic prolapse, where regurgitation occurs only in very late systole 1. 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 1.