Can mitral valve prolapse be fatal in an athlete, especially if there is significant mitral regurgitation or ventricular arrhythmias?

Can Mitral Valve Prolapse Kill an Athlete?

Yes, mitral valve prolapse can be fatal in athletes, though the risk is generally low—MVP accounts for up to 11% of sudden cardiac deaths in young competitive athletes, with an estimated annual SCD rate of 0.2-0.4% in MVP patients. 1

Understanding the Risk Spectrum

While MVP is typically benign, a subset of patients with "arrhythmic MVP" or "malignant MVP" face significantly elevated risk of sudden cardiac death, particularly during or immediately after sports activity. 1, 2

High-Risk Features That Predict Fatal Outcomes

The following characteristics identify athletes at increased risk for sudden death:

• Bileaflet myxomatous prolapse with leaflet thickness ≥5 mm (classic MVP) 1
• Mitral annular disjunction (MAD) on echocardiography 3, 2
• T-wave inversion in inferior leads (II, III, aVF) on 12-lead ECG 3, 2
• Complex ventricular arrhythmias (frequent PVCs, ventricular tachycardia), especially those arising from papillary muscles 1, 3, 2
• Myocardial fibrosis in the left ventricular inferolateral basal region and papillary muscles on cardiac MRI with late gadolinium enhancement 3, 2
• Significant mitral regurgitation (moderate to severe) 1
• Family history of sudden cardiac death attributed to MVP 1, 3
• History of syncope judged to be arrhythmogenic in origin 1
• Prior embolic event 1

Prevalence and Context

MVP occurs in approximately 1.1-2.4% of athletes, similar to the general population prevalence of 2-3%. 1, 4 Despite being the most common valvular abnormality in athletes, most cases are benign and do not preclude sports participation. 4, 5

However, MVP has been identified as an underestimated cause of arrhythmic sudden cardiac death, particularly in young adult women, and represents a disproportionate cause of SCD in the athletic population given its relatively low prevalence. 1

Risk Stratification Algorithm

For athletes diagnosed with MVP, the following evaluation pathway should be implemented:

Initial Assessment

• Detailed family history focusing on sudden cardiac death in relatives with MVP 1, 3
• 12-lead ECG specifically examining for T-wave inversions in inferior/inferolateral leads 3, 2
• Comprehensive echocardiography assessing:
  • Number of leaflets involved (bileaflet vs. single leaflet) 1, 2
  • Leaflet thickness (≥5 mm indicates classic MVP) 1
  • Presence and severity of mitral regurgitation 1
  • Mitral annular disjunction 3, 2
  • Left ventricular size and systolic function 1

Advanced Testing for Intermediate/High-Risk Features

• 24-48 hour ambulatory ECG (Holter monitoring) to detect complex ventricular arrhythmias 1, 3
• Exercise stress testing to at least the level of competitive activity to assess for exercise-induced arrhythmias 1, 3
• Cardiac MRI with late gadolinium enhancement if any high-risk features are present, specifically evaluating for fibrosis in papillary muscles and inferolateral basal wall 3, 2

Sports Participation Recommendations

Athletes Who Can Participate in All Competitive Sports

Athletes with mild MVP meeting ALL of the following criteria: 1

• Asymptomatic
• Sinus rhythm
• No family history of MVP-related sudden death
• Mild or no mitral regurgitation
• Normal left ventricular size and function
• No complex ventricular arrhythmias
• No T-wave abnormalities on ECG

Athletes Restricted to Low-Intensity Sports Only

Athletes with MVP and ANY of the following must be restricted to low-intensity competitive sports (Class IA activities like golf, bowling): 1

• History of syncope judged to be arrhythmogenic
• Family history of sudden death due to MVP
• Repetitive supraventricular or complex ventricular tachyarrhythmias, particularly if exacerbated by exercise
• Moderate to severe mitral regurgitation
• Prior embolic event

Additionally, athletes with high-risk imaging features (MAD with myocardial fibrosis on CMR) should be restricted from competitive sports. 3

Complete Disqualification from Competitive Sports

Athletes with MVP demonstrating the "malignant MVP" phenotype—characterized by bileaflet prolapse, MAD, T-wave inversions, complex ventricular arrhythmias, and myocardial fibrosis—should be disqualified from competitive sports. 3, 2

Critical Pitfalls to Avoid

Do not assume all MVP is benign simply because the patient is asymptomatic. Many athletes who died suddenly from MVP had no symptoms and were not aware of severe risk factors. 1, 2 The absence of severe mitral regurgitation does not exclude high arrhythmic risk. 3, 2

Do not rely solely on echocardiography for risk stratification. Cardiac MRI is essential when any concerning features are present, as myocardial fibrosis is a critical marker of arrhythmic risk that cannot be detected by echocardiography alone. 3, 2

Do not overlook the significance of T-wave inversions in inferior leads. This ECG finding is a specific marker of arrhythmic MVP and warrants comprehensive evaluation including cardiac MRI. 3, 2

Monitoring Requirements

Athletes with MVP who continue sports participation require annual evaluation including: 1

• Physical examination
• 12-lead ECG
• Doppler echocardiography
• Exercise stress testing to the level of competitive activity

This surveillance is essential because MVP can progress over time, and new high-risk features may develop. 1