What is the treatment for mitral valve prolapse?

Treatment of Mitral Valve Prolapse

Treatment for mitral valve prolapse should be stratified by severity of mitral regurgitation (MR) and symptoms, with asymptomatic patients with mild MVP requiring only surveillance, while those with severe MR and symptoms, left ventricular dysfunction, new atrial fibrillation, or pulmonary hypertension should undergo mitral valve repair. 1

Surveillance Strategy for Asymptomatic Patients

Mild MR (Stage A-B):

• Clinical follow-up every 12 months with echocardiography every 2 years 1
• Follow-up every 3-5 years for mild MR 1

Moderate MR:

• Clinical follow-up every 6 months with annual echocardiography 1, 2
• Yearly clinical follow-up with echocardiography every 1-2 years 1

Severe MR without symptoms:

• Clinical evaluation every 6 months with annual echocardiography 1, 2
• Monitor for development of surgical indications 1

Surgical Indications

Symptomatic patients (Stage D):

• Surgery is strongly recommended for all symptomatic patients with chronic severe primary MR and LVEF >30% 1, 2
• Symptom onset alone warrants surgical consideration even if LV function appears preserved 1

Asymptomatic patients with severe MR (Stage C): Surgery should be performed when any of the following develop:

• Left ventricular ejection fraction ≤60% 1, 2, 3
• Left ventricular end-systolic dimension ≥40 mm 1, 2, 3
• New onset atrial fibrillation 1, 2
• Pulmonary hypertension 1, 2

Critical pitfall: Do not delay surgery until symptoms develop or LV dysfunction occurs, as earlier intervention leads to improved survival and functional outcomes 1

Surgical Techniques

Mitral valve repair is strongly preferred over replacement when technically feasible 1, 2, 3

Specific techniques based on pathology:

Posterior leaflet prolapse:

• Focal triangular resection with annuloplasty ring for focal leaflet flail 1, 2
• Sliding leaflet valvuloplasty with annuloplasty ring for diffuse posterior leaflet myxomatous disease 1, 2

Anterior leaflet or bileaflet prolapse:

• Nonresection techniques using PTFE neochord reconstruction or chordal transfer combined with annuloplasty ring 1, 2, 3
• These patients should be referred to experienced mitral valve surgeons at high-volume centers due to technical complexity 1, 3

Percutaneous edge-to-edge repair:

• May be considered for patients at high surgical risk 1, 2

Medical Management

There is no evidence supporting the use of vasodilators, including ACE inhibitors, in chronic MR without heart failure 1, 2

For patients not candidates for surgery:

• 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 therapy:

• Warfarin with target INR 2.0-3.0 is recommended for patients with permanent or paroxysmal atrial fibrillation, history of systemic embolism, or evidence of left atrial thrombus 1
• For patients with MVP and atrial fibrillation: Warfarin for those aged >65 or with hypertension, MR murmur, or history of heart failure 2
• Aspirin for patients <65 years without MR, hypertension, or heart failure 2

For patients with MVP and history of stroke:

• Warfarin for those with MR, atrial fibrillation, or left atrial thrombus 2
• Aspirin is reasonable for patients without these features 2

Antithrombotic therapy for MVP without stroke history:

• Patients with MVP who have not experienced systemic embolism, unexplained TIAs, or ischemic stroke should be treated with antiplatelet agents 4
• Recent population-based studies, including the Framingham Heart Study, have failed to clearly identify an increased risk of stroke in MVP patients 4

Endocarditis Prophylaxis

Endocarditis prophylaxis is recommended for most patients with a definite diagnosis of MVP, particularly if there is associated MR 2

Post-Surgical Follow-up

• Baseline ECG, X-ray, and echocardiography should be established for future comparison 1, 2
• Regular clinical and echocardiographic follow-up to monitor for recurrent MR or complications 3

Common Pitfalls

• Do not rely on color jet area alone to quantify MR severity, as it can be misleadingly small or large 1
• Avoid single-plane measurements of vena contracta in MVP, as the regurgitant orifice may be non-circular 1
• The presence of moderate or greater residual MR at the time of surgery is the most important predictor of long-term repair failure 1, 3