Mitral Valve Prolapse + Flail leaflets

MVP definition

Posterior displacement of any porIon of the MV leaflets beyond the MV annular plane during ventricular systole

other names for MVP

1. Barlow Syndrome

2. Floppy Valve Syndrome

3. Systolic Click-Murmur Syndrome

MVP classifications

1. Classic

2. Non-classic

3. Secondary (functional)

4. echocardiographic types

Classic MVP = primary myxomatous

Increased thickening of MV leaflets

Causes of classic MVP

• Fibrosis

• Mitral annular dilatation

• Chordal redundancy/lengthening

• Fibrin deposits

Classic mitral valve prolapse can be ____ or ______

Familial or Nonfamilial

Non-classical MVP

• No thickening or plumping of leaflets

• Systolic superior displacement of MV leaflets

Non-classical MVP is characterized by:

• Mid-systolic click

• Displacement of leaflets >2 mm

• Valve thickness <5mm (no thickening)

• MR absent or minimal

Secondary (functional) MVP

• reduction/alteration of the LV size/shape

• causes normal MV leaflets to move past the MV annulus

causes of secondary/functional MVP

• CAD

• RHD

• dilated or hypertrophic CM

• Left-to-right shunting

• ASD

• Severe TR

• Ebstein’s anomaly

• Primary pulmonary hypertension

• Pericardial effusion

echocardiographic types of MVP

1. mid to late systolic

   1. holosystolic

signs and symptoms of MVP

★ AsymptomaIc with normal, asthenic phenotype (appearance)

• PalpitaIons – most common presenIng symptom

• Chest pain – atypical

• Dyspnea, exercise intolerance

• Presyncope/syncope

• Neuropsychiatric symptoms (anxiety, panic alacks)

• Cerebrovascular symptoms of TIA, CVA, amaurosis fugax

• Heart failure due to significant MR

Complications of MVP

★ MR – progressive

• InfecIve endocardiIs (MVP is leading cause)

• Embolic events due to fibrin emboli

• Ruptured chordae tendinae with acute MR

• Arrhythmias due to conducIon defects – SVT most common

• Heart failure

• Pulmonary hypertension

• Acute pulmonary edema

• Sudden death (rare) due to ventricular arrhythmias

auscultation for MVP

• mid to late systolic click

  • due to sudden tensing of chordae

  • with or without late systolic murmur due to associated MR

• accentuated S₁

EKG findings for MVP

• Normal

• inverted/biphasic T waves in leads II, III, aVF

• Non specific ST changes

• Arrhythmias – SVT, PVC

• ConducIon disturbances – first degree A-V block, WPW

• LAE with M

what is the 2D view of choice for MVP?

PLAX

Echo findings - 2D PLAX

1. criteria for diagnosis of MVP

2. Diffuse leaflet thickening > 5 mm myxomatous appearance (classic MVP)

3. Scalloped appearance of the involved MV leaflet in PSAX

4. ElongatIon of the chordae

5. LAE (MR)

6. LV volume overload palern (LV dilatatIon and hyperkinesis)

Criteria for diagnosis of MVP - anterior leaflet

any porIon of the leaflet protrudes beyond the annular plane

• ≥ 2 mm in PLAX

• ≥ 1 cm (10 mm)

Criteria for diagnosis of MVP - posterior leaflet

any portion of the leaflet protruding > 2 mm beyond the annular plane with visualization of the various scallops in different

views:

− PLAX and AP 3-Ch for A2 & P2

− AP 4-Ch and AP 5-Ch for A3 & P1

− AP 2-Ch for A1 & P3

M-mode findings

• mid to late systolic “sagging” back of the anterior, posterior or both MV leaflets > 2 mm from the C-D points

• holosystolic (pansystolic) “sagging” back of the anterior, posterior or both MV leaflets from ≥ 3 mm from the C-D points of the MV

Doppler findings

in occurrence of severe MR in MVP

• DilatIon of the mitral annulus between 14 – 18 cm (N = 9 cm)

• Rupture of chordae tendineae with or without mitral annular dilataIon

Treatment for MVP

• None for asymptomatIc patients, good hydration to prevent volume depletion

• Antibiotoic prophylaxis before minor surgical and dental procedures

• CessatIon of stimulants: caffeine, alcohol

• InvestIgatIon of arrhythmias/conductIon disturbances: EP study, Holter monitor, exercise stress test

• Beta-blockers, antiarrhythmics

• AntIcoagulatIon (LAE)

• ASA therapy for TIA, CVA patients

• MV replacement – TEE evaluation necessary pre and post operation

Flail MV leaflets

a severe form of mitral valve prolapse where a leaflet segment ruptures and swings backward into the left atrium during systole

difference between flail and prolapse

• Prolapse - leaflet protrudes into LA, but is still attached to chordae

• Flail - not attached to chordae, “flailing” around LA

rupture of several isolated chordae → _____

absent MR

rupture of entire PM or PM head → _____

acute severe MR

MR jet with flail leaflet will be ____ with an orientation ____ in direction to defect leaflet

1. eccentric

2. opposite

ruptured posterior chordae + flail posterior leaflet → _____ jet

anteroseptal MR

ruptured anterior chordae + flail anterior leaflet → _____ jet

postero / inferolateral MR

CW appearance of flail leaflets

Due to the eccentric jet, the MR spectral signal may have an atypical appearance due to the CW cursor intersecting the jet partially.

This may result in varying density and velocity of the signal, mimicking _______

less than a holosystolic jet

if there are parts of the flail portions that oscillate in the regurgitation flow stream, they result in a “______” appearance of the spectral signal associated with a “_____” sound

1. tiger stripe

2. whistling

Surgical repair of flail leaflets

• Partial flail: placing of annuloplasty ring + resection of flail portion

• Placement of prosthetic chordae

• Chordal shortening procedures

• TranslocatIon of chordae from one leaflet to another

carpentier’s functional classification of MR is based on…

the opening and closing motion of both leaflets

Based on leaflet motion, there are 3 types of functional mitral regurgitation

1. type I MR

2. type II MR

3. type III MR

type I MR

• MR occurs despite normal leaflet motion

• cause: annular dilatation (dilated CM) or leaflet perforation (sequelae of endocarditis)

• MR jet is central

type II MR

• Occurs because of leaflet prolapse due to simple elongation of the leaflet or flail leaflet due to chordal /PM rupture

• MR jet is eccentric

type III MR - a

Restricted leaflet motion (in systole and diastole)

• Valvular/subvalvular thickening

• MAC due to aging, sequelae of RHD

• MR jet can be eccentric/central

type III MR - b

Restricted leaflet motion (in systole)

• Displacement of PM (elongation associated with dilated CM), chordae apical tethering

• MR jet is central