Mitral valve prolapse in children

Mitral valve prolapse (Angle syndrome, Barlow syndrome, midsystolic click and late systolic murmur syndrome, flapping valve syndrome) is a deflection and bulging of the valve cusps into the cavity of the left atrium during left ventricular systole.

Mitral valve prolapse is a common pathology of the heart and, in particular, its valvular apparatus.

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What causes mitral valve prolapse in children?

In childhood, mitral valve prolapse is detected in 2.2-14% of children in a population study. In organic heart pathology, it is detected in 10-30% of patients. Mitral valve prolapse can be found in the structure of various diseases, and can also be an isolated echocardiographic phenomenon. All types of mitral valve prolapse are divided into congenital and acquired, primary (isolated, idiopathic) and secondary - as complicated (in rheumatism, carditis) or an accompanying symptom (in heart defects, pericarditis, Marfan's disease, Ehlers-Danlos disease, etc.). In children, along with the presence of mitral valve prolapse, minor developmental anomalies (dysraphic stigmata) are often found, indicating congenital inferiority of the connective tissue, while VD is detected. In this case, we are talking about an isolated variant of mitral valve prolapse, since in other cases mitral valve prolapse is a symptom of a cardiac disease.

Among isolated mitral valve prolapses, two forms are distinguished: auscultatory (systolic clicks and late systolic murmur) and silent (mitral valve prolapse is detected only by echocardiography).

It is currently believed that mitral valve prolapse can occur due to a number of reasons of both a morphofunctional nature (anomalies in the structure and attachment of the valve apparatus, deformations as a result of previous inflammatory diseases, etc.), and as a result of a violation of the autonomic regulation of the valves and subvalvular apparatus against the background of psychovegetative syndrome.

Symptoms of Mitral Valve Prolapse in Children

Mitral valve prolapse is most often detected in children aged 7-15 years, but can be diagnosed at any age.

The auscultatory form of isolated (idiopathic) prolapse is detected 5-6 times more often in girls. The early anamnesis is full of pathological pregnancy, viral infections, and the threat of termination of pregnancy. It is especially necessary to note the unfavorable course of the early antenatal period, i.e., when the differentiation of the heart structures and its valve apparatus occurs.

In the pedigree of a child with mitral valve prolapse, ergotropic circle diseases are often determined in close relatives. Familial nature of mitral valve prolapse is noted in 10-15% of children, and on the mother's side. Signs of connective tissue deficiency (hernias, scoliosis, varicose veins, etc.) are traced in the pedigree of the proband.

The psychosocial environment is usually unfavorable, there are often conflict situations in the family, at school, which are combined with certain emotional and personal characteristics of the patient (high level of anxiety, neuroticism). Children with mitral valve prolapse usually differ from healthy children by a high incidence of acute respiratory viral infections, they often have sore throats, chronic tonsillitis.

Among children with isolated mitral valve prolapse, 75% have the following symptoms of mitral valve prolapse: complaints of chest pain, palpitations, a feeling of interruptions in the heart, shortness of breath, dizziness. As with all patients with vegetative dystonia, they are characterized by headaches and a tendency to fainting. Cardialgia in children with mitral valve prolapse has its own characteristics: it is "stabbing", "aching", without irradiation, short-term (seconds, less often minutes), usually occurs against the background of emotional stress and is not associated with physical exertion. Pain syndrome is relieved by taking sedatives (tincture of valerian, valocordin). Dizziness often occurs when standing up abruptly, in the first half of the day, during long breaks between meals. Headaches are more common in the morning, occur against the background of fatigue, anxiety. Children complain of irritability, disturbed night sleep. With orthostatic hypotension, fainting may occur, more often of a reflex type. The cardiological picture of mitral valve prolapse is varied and is described in detail in the manuals.

Clinical differentiation of mitral valve prolapse variants is important, allowing to determine the cause and treatment tactics. In addition to cardiological indicators (echocardiography), studies of the autonomic nervous system and emotional sphere features are of great importance.

When examining children with mitral valve prolapse, attention is drawn to frequent signs of dysplastic structure: asthenic build, flat chest, tall stature, poor muscle development, increased mobility in small joints, girls are fair-haired and blue-eyed; among other stigmas, gothic palate, flat feet, sandal-shaped gap, myopia, general muscular hypotonia, arachnodactyly are determined; more severe pathology of the musculoskeletal system is funnel chest, straight back syndrome, inguinal, inguinal-scrotal and umbilical hernias.

When examining the emotional and personal sphere in children with idiopathic mitral valve prolapse, increased anxiety, tearfulness, excitability, mood swings, hypochondria, and fatigue are recorded. These children are characterized by numerous fears (phobias), often fear of death if the child develops a vegetative paroxysm, which is a fairly common condition in such patients. The mood of children with prolapse is variable, but a tendency to depressive and depressive-hypochondriacal reactions is still noted.

The autonomic nervous system is of exceptional importance in the clinical course of mitral valve prolapse; as a rule, sympathicotonia predominates. In some children (usually with a greater degree of prolapse of the valves) with a rough late- and holosystolic murmur, according to the indicators of cardiointervalography (CIG) and clinical autonomic tables, signs of parasympathetic activity against the background of a high level of catecholamines can be determined.

In this case, the increase in the tone of the vagus nerve is compensatory in nature. At the same time, the presence of both hypersympathicotonia and hypervagotonia creates conditions for the occurrence of life-threatening arrhythmias.

Three clinical variants of the auscultatory form of mitral valve prolapse are distinguished depending on the severity of the course. In the first clinical variant, isolated clicks are detected during auscultation. There are few minor developmental anomalies. The vegetative tone is characterized as hypersympathicotonia, the reactivity is asympathicotonic. The vegetative support of activity is excessive. In general, deterioration in the adaptation of the cardiovascular system to the load is noted. In the second clinical variant, mitral valve prolapse has the most typical manifestations. Late systolic prolapse of the cusps of moderate depth (5-7 mm) is detected on the echocardiogram. The sympathicotonic direction of vegetative shifts prevails in the status. The vegetative reactivity is hypersympathicotonic in nature, the vegetative support of activity is excessive. In the third clinical variant of auscultatory mitral valve prolapse, significant deviations in clinical and instrumental parameters are revealed. The status is a high level of minor developmental anomalies, with an isolated late systolic murmur upon auscultation. An echocardiogram reveals a late systolic or holosystolic prolapse of the mitral valve leaflets of great depth. When examining the vegetative tone, the predominance of the influences of the parasympathetic division of the autonomic nervous system, or a mixed tone, is determined. Vegetative reactivity is increased, of a hypersympathicotonic nature, and the provision of activity is excessive. These patients are distinguished by the lowest indicators of physical performance and have the most maladaptive reactions of the cardiovascular system to loads.

Thus, the degree of dysfunction of the heart valve apparatus is directly dependent on the severity of the course of vegetative dystonia.

The silent form of mitral valve prolapse is very common, occurring equally often in girls and boys. The early anamnesis is also burdened with perinatal pathology, frequent acute respiratory viral infections, which further contributes to the development of vegetative dystonia and mitral valve dysfunction.

Complaints and ECG changes are absent in many cases - these are practically healthy children. In the presence of various complaints (fatigue, irritability, headache, stomach, heart pain, etc.), detection of mitral valve prolapse confirms the presence of vegetative dystonia syndrome. In most children, the number of minor developmental anomalies does not exceed 5 or a moderate increase in the level of stigmatization is noted (tall stature, Gothic palate, "looseness" of joints, flat feet, etc.), which, in combination with proportional physical development, indicates an insignificant role of constitutional factors in the occurrence of prolapse of the valves in children with a silent form of mitral valve prolapse.

The state of the autonomic nervous system in children with silent prolapse is most often characterized by autonomic lability, less often there is dystonia of the parasympathetic or mixed type. Panic attacks in children with mitral valve prolapse are not more common than in other groups, and if they occur relatively rarely, they do not have a significant impact on the life and well-being of children with mitral valve prolapse.

Vegetative support of activity in these patients is usually normal, less often insufficient (hyperdiastolic variant of clinoorthotest). When conducting bicycle ergometry, the indicators of physical performance and work performed with silent mitral valve prolapse differ little from the norm compared to these indicators with the auscultatory form of mitral valve prolapse.

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Treatment of mitral valve prolapse in children

The main treatment for mitral valve prolapse is compliance with the regime. Children with silent variants of mitral valve prolapse, who do not have repolarization process disorders on the ECG, can play sports and physical education without any restrictions. In other variants, these issues are resolved by a cardiologist after examining each patient individually. Treatment of vegetative dystonia is carried out according to general rules.

What is the prognosis for mitral valve prolapse in children?

Mitral valve prolapse usually has a favorable prognosis. Pediatricians often exaggerate the prognostic significance and danger of this syndrome for health and life of people. Only children with a full symptom complex (the so-called third clinical variant of auscultatory mitral valve prolapse) need treatment and health measures, ECG, echocardiography 2-3 times a year with consultation of a neurologist, psychologist. In the first, second and intermediate variants of silent mitral valve prolapse, medical examination is carried out 2 times a year. In the silent form of mitral valve prolapse, it is advisable to show the child to the doctor once a year with echocardiography.