Treatment of mitral valve prolapse

Treatment of mitral valve prolapse consists of eliminating the symptoms of cardialgia, palpitations, increased fatigue and anxiety. In many cases, it may be sufficient to stop drinking coffee, alcohol and smoking, normalize the physical activity regimen, psychotherapeutic measures and sedative treatment. Drug correction of cardialgia, palpitations, supraventricular and ventricular extrasystole is based on the prescription of beta-adrenergic receptor blockers. Given the etiopathogenetic role of magnesium deficiency in the development of cardiac and neuropsychiatric symptoms, patients with mitral valve prolapse may be recommended to use magnesium preparations. Symptoms of postural hypotension are corrected by increasing fluid and table salt intake (increasing the volume of circulating blood), wearing elastic stockings (compression of the lower extremities) may be recommended. Sports activities in patients with mitral valve prolapse are excluded in the presence of syncope, uncontrolled tachyarrhythmias, prolonged QT interval, moderate dilation and dysfunction of the left ventricle, and dilation of the aortic root.

Further medical tactics are aimed at preventing complications of mitral valve prolapse.

According to the American Heart Association, there are three groups of patients with MVP depending on the degree of risk of complications.

1. The low-risk group includes patients with no systolic murmur of mitral regurgitation during auscultation, structural changes in the valves, tendinous chordae, papillary muscles, fibrous ring of the mitral valve and mitral regurgitation according to echocardiography. Patients should be informed about the favorable course of mitral valve prolapse and the absence of the need to limit physical activity. Dynamic observation with auscultation of this group of patients is indicated at intervals of 3-5 years.
2. The moderate-risk group should include patients with MVP in the presence of thickening and/or excessive enlargement of the mitral valve leaflets, thinning and/or elongation of the chordae tendineae according to Doppler echocardiography; intermittent or persistent systolic murmur associated with mitral regurgitation; minor mitral regurgitation according to Doppler examination. Routine echocardiographic examination in case of minor mitral regurgitation is not necessary, provided that the clinical picture is stable. Dynamic echocardiography is indicated for patients with MVP who develop symptoms associated with concomitant cardiovascular diseases. Due to the negative impact of the addition of arterial hypertension, which contributes to an increase in the degree of mitral regurgitation in mitral valve prolapse, such patients require careful monitoring of blood pressure and the appointment of adequate antihypertensive treatment.
3. The group with a high risk of complications includes individuals with moderate or severe mitral regurgitation. Such patients require annual examination using echocardiography, careful monitoring of blood pressure with the prescription of antihypertensive treatment.

Drug treatment of mitral valve prolapse

Long-term use of warfarin is recommended for patients with mitral valve prolapse who have had cerebrovascular accidents and have concomitant mitral regurgitation, atrial fibrillation, or a thrombus in the left atrium. It is necessary to maintain the INR in the range of 2.0-3.0.

Treatment of mitral valve prolapse combined with atrial fibrillation involves the use of warfarin, which is indicated in the following cases:

• Age over 65 years.
• Associated mitral regurgitation.
• Arterial hypertension
• Heart failure

In all other cases, the use of aspirin is sufficient.

Guidelines for the treatment of patients with symptomatic mitral valve prolapse (ACC/AHA, 2006)

Recommendations	Class	Level of evidence
Aspirin* (75-325 mg/day) is indicated in patients with symptomatic MVP and a history of transient ischemic attack	I	WITH
Warfarin is indicated in patients with MVP and atrial fibrillation over the age of 65 years with arterial hypertension, mitral regurgitation murmur, or signs of heart failure.	I	WITH
The use of aspirin* (75-325 mg/day) is indicated for patients with MVP and atrial fibrillation under 65 years of age without mitral regurgitation, arterial hypertension and signs of heart failure	I	WITH
Patients with MVP and a history of acute cerebrovascular accident (ACVA) are indicated for treatment with warfarin if there is mitral regurgitation, atrial fibrillation or left atrial thrombosis	I	WITH
In patients with a history of MVP and CVA without mitral regurgitation, atrial fibrillation or left atrial thrombosis, warfarin is indicated in case of echocardiographic signs of mitral leaflet thickening (>5 mm) and/or enlargement (redundancy) of the valve leaflet.	II A	WITH
Patients with a history of MVP and CVA without mitral regurgitation, atrial fibrillation or left atrial thrombosis, as well as the absence of echocardiographic signs of mitral leaflet thickening (>5 mm) and/or valve leaflet enlargement (redundancy) are recommended to take aspirin*	II A	WITH
Warfarin is indicated for patients with MVP and the development of a transient ischemic attack during treatment with aspirin*	II A	WITH
The use of aspirin* (75-325 mg/day) is indicated for patients with a history of mitral valve prolapse and acute cerebrovascular accident in the presence of contraindications to taking anticoagulants	II A	IN
The use of aspirin* (75-325 mg/day) may be recommended for patients with MVP and sinus rhythm if there is a high risk of complications according to echocardiography data	II B	WITH

* Classification of recommendations based on their weight and evidence: Class I - there is evidence and/or general agreement that a procedure or treatment method is useful and effective; Class II - there is conflicting evidence and/or expert opinion on the usefulness or effectiveness of an intervention (Class IIA - more evidence or opinion in favor of an intervention, Class IIB - the appropriateness of an intervention is less obvious). Level of evidence C (low) - recommendations are based primarily on expert agreement.

Surgical treatment of mitral valve prolapse

Surgical treatment of mitral valve prolapse is indicated in cases of rupture of the chords or their pronounced elongation and in cases of severe mitral regurgitation accompanied by symptoms of heart failure, as well as in the absence of the latter, but in the presence of severe dysfunction of the left ventricle and systolic pressure in the pulmonary artery >50 mm Hg.

The most common type of surgical intervention is mitral valve plastic surgery, which is characterized by low surgical mortality and a good long-term prognosis.

Leading Russian specialists (Storozhakov G.I. and others) proposed the following recommendations for risk stratification and tactics for managing patients with mitral valve prolapse.

Risk stratification and management tactics for patients with mitral valve prolapse

Groups		Criteria		Tactics of management
Low risk		The presence of an isolated systolic click. The depth of the mitral valve is less than 10 mm, myxomatous degeneration of 0 degree, clinical manifestations are absent or are caused by the syndrome of psychovegetative dysfunction		Explanation of the benign nature of cardiac pathology, correction of psychovegetative dysfunction is recommended, preventive examination every 3-5 years, dynamic echocardiography monitoring is not indicated
Medium risk		The presence of an isolated systolic click, the depth of the mitral valve protrusion is more than 10 mm, myxomatous degeneration of grades I-II, mitral regurgitation is absent or insignificant, age over 45 years, the presence of arterial hypertension, foci of chronic infection, migraine		Prevention of infective endocarditis and thromboembolic complications (taking aspirin) is recommended. Dynamic monitoring is indicated, including echocardiography control every 3-5 years. Correction of hypertension, sanitation of foci of chronic infection
High risk		The presence of a systolic click and late systolic murmur, the depth of the mitral valve protrusion is more than 12 mm, myxomatous degeneration of grades II-III, moderate and/or severe mitral regurgitation, age over 50 years, the presence of atrial fibrillation, arterial hypertension, moderate dilation of the heart cavities without a significant decrease in contractility indices, heart failure (I-II FC)		Moderate limitation of physical activity, prevention of infective endocarditis, thromboembolic complications (including taking indirect anticoagulants), treatment of heart failure are recommended.
Very high risk		The presence of a systolic click with a late systolic murmur or isolated systolic murmur, myxomatous degeneration grade III, severe mitral regurgitation, atrial fibrillation, enlarged chambers of the heart, heart failure III-IV FC, decreased myocardial contractility, history of transient ischemic attack or stroke, history of infective endocarditis		Prevention of infective endocarditis and thromboembolic complications (taking indirect anticoagulants), regular clinical and echocardiographic monitoring are recommended. If indicated - surgical treatment

How to prevent mitral valve prolapse?

Prevention of mitral valve prolapse has not been developed.

If a diagnosis of MVP is established, especially in combination with regurgitation, prophylaxis of infective endocarditis is indicated during procedures that involve bacteremia. According to the American Heart Association (2006), prophylaxis of infective endocarditis is indicated for patients with MVP in the presence of:

1. auscultatory sign of valvular regurgitation (systolic murmur);
2. thickening of the valves (signs of myxomatous degeneration) according to echocardiography;
3. Echocardiography of signs of mitral regurgitation.

Prevention of infective endocarditis is not indicated in patients with MVP without mitral regurgitation and signs of mitral leaflet thickening according to echocardiography.

According to the European Society of Cardiology (2007), prophylaxis of infective endocarditis in MVP is indicated in the presence of mitral regurgitation and/or significant thickening of the mitral valve leaflets.

However, the approach to prevention of infective endocarditis should be individualized, since in one third of patients with MVP, auscultatory signs of valve regurgitation appear after physical exertion and may also be intermittent at rest. In addition, patients with MVP without echocardiographic data of mitral regurgitation with signs of thickening and/or increase in the size of the leaflet (especially males over 45 years old) are susceptible to the development of infective endocarditis. When prescribing preventive measures for infective endocarditis, the type and anatomical area of the proposed invasive intervention, previous history of endocarditis are also taken into account.

Mitral valve prolapse prognosis

Most asymptomatic patients with mitral valve prolapse have a good prognosis, but patients with mitral regurgitation are at high risk of cardiovascular complications and mortality.