What is the treatment for mitral valve prolapse?

Treatment of Mitral Valve Prolapse

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

Surveillance Strategy for Asymptomatic Patients

The management approach depends entirely on the severity of mitral regurgitation, not just the presence of prolapse itself:

Mild Mitral Regurgitation:

• Clinical follow-up every 12 months with echocardiography every 2 years 1
• Some guidelines suggest extending echocardiography intervals to every 3-5 years for truly mild disease 1

Moderate Mitral Regurgitation:

• Clinical follow-up every 6 months with annual echocardiography 1, 2
• Watch specifically for progressive left atrial enlargement, which signals worsening hemodynamic burden and risk of atrial fibrillation 1

Severe Mitral Regurgitation (Asymptomatic):

• Clinical evaluation every 6 months with annual echocardiography 1, 2
• Monitor closely for surgical triggers: left ventricular end-systolic dimension ≥40 mm, left ventricular ejection fraction ≤60%, new atrial fibrillation, or pulmonary hypertension 1, 2

Medical Therapy

There is no role for vasodilators (including ACE inhibitors) in chronic mitral regurgitation without heart failure. 1, 2 This is a critical point—these medications do not prevent progression or delay the need for surgery in asymptomatic patients.

For patients with advanced symptoms who are not surgical candidates:

• ACE inhibitors should be used 1, 2
• Beta-blockers and spironolactone as appropriate for heart failure management 1

For arrhythmias:

• Beta-blockers are the primary treatment for frequent ventricular ectopy (>30/hour), ventricular tachycardia, or symptomatic palpitations 3

Anticoagulation Strategy

For patients with atrial fibrillation (permanent or paroxysmal):

• Warfarin with target INR 2.0-3.0 is recommended 1, 2

For patients with history of systemic embolism or left atrial thrombus:

• Warfarin with target INR 2.0-3.0 1

For patients with MVP and prior stroke/TIA:

• Antiplatelet therapy (not anticoagulation) is recommended for those without mitral regurgitation, atrial fibrillation, or left atrial thrombus 4, 2
• Recent population-based studies, including the Framingham Heart Study, have failed to clearly identify increased stroke risk in uncomplicated MVP 4

Surgical Indications

Surgery is mandatory for:

• All symptomatic patients with severe mitral regurgitation and LVEF >30% 1, 2
• The presence of symptoms alone (decreased exercise tolerance or exertional dyspnea) warrants surgery even if left ventricular function appears preserved on standard measurements 1

Surgery should be performed in asymptomatic patients with severe mitral regurgitation when ANY of the following develop:

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

Mitral valve repair is strongly preferred over replacement when technically feasible. 1, 2 Repair has lower operative mortality and avoids prosthetic valve complications.

Surgical Technique Selection

The specific repair technique depends on the anatomic pattern of prolapse:

Focal posterior leaflet prolapse:

• Focal triangular resection with annuloplasty ring 1, 2

Anterior leaflet or bileaflet prolapse:

• Nonresection techniques using PTFE neochord reconstruction or chordal transfer with annuloplasty ring 1, 2, 5
• These patients require referral to experienced mitral valve surgeons at high-volume centers due to technical complexity 1, 5

Diffuse posterior leaflet myxomatous disease (Barlow's disease):

• Sliding leaflet valvuloplasty with annuloplasty ring 1
• Should not be attempted without referral to expert centers 1

Critical Pitfalls to Avoid

Do not delay surgery until symptoms develop or left ventricular dysfunction occurs—earlier intervention leads to improved survival and functional outcomes. 1 Symptom onset is itself a negative prognostic event even with preserved left ventricular function. 1

Do not rely on symptom improvement with diuretics to defer surgery—this does not change the prognostic significance of symptom onset. 1

Do not use color jet area alone to quantify mitral regurgitation severity, as it can be misleadingly small or large. 1 Use quantitative parameters: effective regurgitant orifice area ≥0.4 cm² and regurgitant volume ≥60 mL define severe primary mitral regurgitation. 1, 2

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 mitral regurgitation at the time of surgery is the most important predictor of long-term repair failure. 1, 5

Endocarditis Prophylaxis

Endocarditis prophylaxis is recommended for patients with MVP who have an associated mitral regurgitation murmur, particularly prior to dental procedures or surgery. 2, 3 Infectious endocarditis occurs in approximately 2.9% of MVP patients. 3

Post-Surgical Follow-up

After repair or replacement, establish baseline ECG, chest X-ray, and echocardiography for future comparison. 1, 2 Regular clinical and echocardiographic surveillance is essential to monitor for recurrent mitral regurgitation or other complications. 5