What is the recommended management approach for a patient with mitral prolapse?

Management of Mitral Valve Prolapse

Mitral valve prolapse management is stratified by severity of mitral regurgitation (MR) and presence of symptoms, with asymptomatic patients requiring only surveillance while those with severe MR and specific high-risk features—including symptoms, left ventricular dysfunction (LVEF <60% or LVESD ≥40mm), new atrial fibrillation, or pulmonary hypertension—should undergo mitral valve repair at experienced centers. 1, 2

Risk Stratification and Initial Assessment

The first step is comprehensive echocardiographic evaluation to determine disease stage and identify high-risk features 1, 2:

High-risk features predicting complications include:

• Leaflet thickness ≥5mm (strongest predictor of endocarditis, severe MR, need for replacement, and ventricular arrhythmias) 1, 3
• Bileaflet prolapse, particularly in women with T-wave abnormalities and complex ventricular ectopy 3
• Redundant leaflets with myxomatous degeneration 3
• Male gender over 45 years 3

Severity quantification requires integrative assessment:

• Severe primary MR: EROA ≥0.4 cm² and regurgitant volume ≥60 mL 1, 2
• Vena contracta ≥7mm indicates severe MR 1
• Left ventricular end-systolic dimension (LVESD) ≥40mm is a Class I surgical indication even when asymptomatic 1

Surveillance Protocol Based on MR Severity

For mild MR (asymptomatic):

• Clinical follow-up every 12 months 1, 3
• Echocardiography every 2 years 1, 2

For moderate MR (asymptomatic):

• Clinical follow-up every 6 months 1, 2
• Echocardiography annually 1, 2

For severe MR (asymptomatic):

• Clinical evaluation every 6 months 1, 2
• Echocardiography annually 1, 2

Medical Management

There is no role for vasodilators (including ACE inhibitors) in chronic MR without heart failure. 1, 2

Medical therapy is reserved for specific situations:

• ACE inhibitors: Only for advanced MR with severe symptoms in non-surgical candidates 1, 2
• Beta-blockers and spironolactone: For standard heart failure management when indicated 1
• Anticoagulation (target INR 2-3): For permanent or paroxysmal atrial fibrillation, history of systemic embolism, or left atrial thrombus 1, 2

Surgical Indications

Immediate surgical referral is indicated for:

Symptomatic patients:

• All symptomatic patients with chronic severe primary MR and LVEF >30% 1, 2, 3
• Symptom onset is itself a negative prognostic event even with preserved LV function; symptom improvement with diuretics does not change this 1, 3

Asymptomatic patients with severe MR when ANY of the following develop:

• LVEF <60% 1, 2, 3
• LVESD ≥40mm 1, 2, 3
• New-onset atrial fibrillation 1, 2, 3
• Pulmonary hypertension 1, 2, 3

Surgical Technique Selection

Mitral valve repair is strongly preferred over replacement when technically feasible. 1, 2, 4

Technique depends on specific pathology:

For focal posterior leaflet flail (fibroelastic deficiency):

• Focal triangular resection with annuloplasty ring 1, 2
• Highest success rate; should never undergo replacement without attempted repair 3
• Can be managed by most experienced surgeons 3

For anterior leaflet or bileaflet prolapse:

• Nonresection techniques using PTFE neochord reconstruction or chordal transfer with annuloplasty ring 1, 2, 3
• Requires referral to experienced mitral valve surgeon at high-volume center 1, 3

For diffuse posterior leaflet myxomatous disease:

• Sliding leaflet valvuloplasty with annuloplasty ring 1, 2

For Barlow's disease (extensive bileaflet involvement):

• Mandatory referral to high-volume Heart Valve Center of Excellence 1, 3
• Should not be attempted without expert mitral valve repair experience 1

Critical Pitfalls to Avoid

Do not delay surgery until symptoms develop or LV dysfunction occurs—earlier intervention leads to improved survival and functional outcomes 1, 3

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

Echocardiographic assessment can underestimate severity in late-systolic prolapse where regurgitation occurs only in very late systole 1

Special Considerations

For patients at high surgical risk, percutaneous edge-to-edge repair (TEER) may be considered 5, 1, 2

Endocarditis prophylaxis is recommended for most patients with definite MVP, particularly with associated MR 2

ICD implantation should be considered for patients presenting with sustained ventricular tachyarrhythmias, particularly those with LV fibrosis in papillary muscles 3