Treatment of mitral valve prolapse

Treatment of mitral valve prolapse is to eliminate symptoms of cardialgia, palpitations, increased fatigue and anxiety. In many cases, cancellation of coffee, alcohol and smoking, normalization of the exercise regime, psychotherapeutic measures and sedative treatment may be sufficient. Medication correction of cardialgias, palpitations, supraventricular and ventricular extrasystoles is based on the appointment of beta-adrenoreceptor blockers. Given the etiopathogenetic role of magnesium deficiency in the development of cardiac and neuropsychic symptoms, patients with PMC may be recommended to use magnesium preparations. Symptoms of postural hypotension are corrected by increased intake of liquid and table salt (increase in the volume of circulating blood), it is recommended to wear elastic stockings (compression of the lower limbs). Sports loads in patients with mitral valve prolapse are excluded in the presence of syncopal conditions, uncontrolled tachyarrhythmias, prolonged QT interval, moderate expansion and left ventricular dysfunction, dilatation of the root of the aorta.

Further medical tactics is reduced to preventing complications of mitral valve prolapse.

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

1. The low-risk group includes patients with no systolic murmur of mitral regurgitation in auscultation, structural changes in the valves, tendon chords, papillary muscles, fibrotic mitral valve ring, and mitral regurgitation according to DEHC. Patients should be informed about the favorable course of mitral valve prolapse and there is no need to limit exercise. Dynamic observation with auscultation to this group of patients is shown with an interval of 3-5 years.
2. In a moderate risk group, patients with PMC should be included in the presence of thickening and / or excessive enlargement of the mitral valve flaps, thinning and / or lengthening of the tendon chords given by the DEHC; intermittent or persistent systolic noise associated with mitral regurgitation; minor mitral regurgitation according to the Doppler study. Routine echocardiographic examination with a slight severity of mitral regurgitation is not necessarily provided a stable clinical picture. Echocardiography in dynamics is indicated for patients with PMC, who have symptoms associated with concomitant cardiovascular diseases. In connection with the negative effect of adherence of arterial hypertension, which contributes to the increase in the degree of mitral regurgitation in mitral valve prolapse, such patients need careful monitoring of blood pressure and the appointment of adequate antihypertensive treatment.
3. The group with a high risk of developing complications includes people with moderate or severe mitral regurgitation. Such patients need an annual examination with the use of DEHC, careful monitoring of blood pressure with the appointment of antihypertensive treatment.

Medicinal treatment of mitral valve prolapse

Long-term use of warfarin is recommended for patients with mitral valve prolapse who underwent cerebral circulatory disorders and who have concomitant mitral regurgitation, atrial fibrillation, or a thrombus in the left atrium. It is necessary to maintain INR in the range 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. 
• Concomitant mitral regurgitation. 
• Arterial hypertension 
• Heart failure

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

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

Recommendations	Class	Level of Evidence
Taking aspirin * (75-325 m g / su g) is indicated in patients with symptomatic PMS and transient ischemic attack in the history	I	FROM
The use of warfarin is indicated in patients with PMC and atrial fibrillation over the age of 65 pet with arterial hypertension, mitral regurgitation noise or signs of heart failure	I	FROM
The use of aspirin * (75-325 mg / oout) is indicated in patients with PMC and atrial fibrillation under the age of 65 without mitral regurgitation, hypertension and signs of heart failure	I	FROM
Patients with PMC and acute cerebrovascular accident (CIN) have a history of treatment with warfarin if there is mitral regurgitation, atrial fibrillation, or left atrial thrombosis	I	FROM
Patients with PMC and ONMC who have a history without mitral regurgitation, atrial fibrillation, or thrombosis of the left atrium show the use of warfarin in the case of echocardiographic signs of mitral flapping (> 5 mm) and / or increase (redundancy) of the valve leaflet	II A	FROM
Patients with PMK and ONMC who have no history of mitral regurgitation, atrial fibrillation or left atrial thrombosis, and no echocardiographic signs of thickening of the mitral valve (> 5 mm) and / or an increase in the valve flap are indicated for taking aspirin *	II A	FROM
Patients with PMP and the development of transient ischemic attack in the background of treatment with aspirin * shows the use of warfarin	II A	FROM
The use of aspirin * (75-325 mg / day) is indicated in patients with PMK and ONMC in an anamnesis in the presence of contraindications to taking anticoagulants	II A	AT
The use of aspirin * (75-325 mg / day) can be recommended for patients with PMP and sinus rhythm with a high risk of complications from echocardiography	II B	FROM

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

Surgical treatment of mitral valve prolapse

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

The most frequent form of surgical intervention is mitral valve plastic, which is characterized by low operational mortality and a good long-term prognosis.

Leading Russian specialists (GI Storozhakov and others) proposed the following recommendations for risk stratification and management tactics for patients with PMP.

Risk stratification and management of patients with mitral valve prolapse

Groups		Criteria		Tactics of reference
Low risk		Presence of an isolated systolic click. depth of PMC less than 10 mm, myxomatous degeneration of the 0th degree, clinical manifestations absent or due to the syndrome of psycho-vegetative dysfunction		Explanation of the benign nature of cardiac pathology, correction of psycho-vegetative dysfunction is recommended, prophylactic examination with a periodicity of 3-5 years, dynamic echocardiography is not shown
Average risk		The presence of an isolated systolic click, the depth of the PMC is more than 10 mm, myxomatous degeneration of the I-II degree, mitral regurgitation is absent or insignificant, the age is over 45, the presence of arterial hypertension, foci of chronic infection, migraine		It is recommended to prevent infectious endocarditis, thromboembolic complications (taking aspirin). Dynamic observation is shown, including EchoCG control every 3-5 years. Correction of hypertension, sanation of foci of chronic infection
High risk		The presence of systolic flicks and late systolic murmur, the depth of the MCA is more than 12 mm, myxomatous degeneration of II-III degree is moderate and / or severe mitral regurgitation, age over 50 years, presence of atrial fibrillation, arterial hypertension, moderate expansion of the heart cavities without significant reduction in contractility, heart failure (I-II FC)		Recommended moderate limitation of physical activity, prevention of infective endocarditis, thromboembolic complications (including the use of indirect anticoagulants), treatment of heart failure
Very high risk		The presence of systolic flicks with late systolic murmur or isolated systolic murmur, myxomatous degeneration of the third degree, expressed mitral regurgitation, atrial fibrillation, enlargement of the chambers of the heart, cardiac insufficiency III-IV FK, decreased myocardial contractile function, transient ischemic attack or ONMC in history, infectious endocarditis anamnesis		Prevention of infective endocarditis and thromboembolic complications (the use of indirect anticoagulants), regular clinical echocardiographic observation are recommended. With indications - surgical treatment

How to prevent mitral valve prolapse?

Prophylaxis of mitral valve prolapse has not been developed.

With the established diagnosis of PMC, especially in combination with regurgitation, the prevention of infective endocarditis is indicated in the procedures accompanied by bacteraemia. According to the American Heart Association (2006), the prevention of infective endocarditis is indicated in patients with PMC in the presence of:

1. auscultative sign of valvular regurgitation (systolic noise); 
2. thickening of valves (signs of myxomatous degeneration) according to echocardiography;
3. EchoCG signs of mitral regurgitation.

Prevention of infectious endocarditis is not indicated in patients with PMC without mitral regurgitation and signs of thickening of mitral valves according to the data of DEHC.

According to the European Society of Cardiology (2007), the prevention of infective endocarditis in PMC is indicated in the presence of mitral regurgitation and / or a significant thickening of the valves of the mitral valve.

However, the approach to prevention of infective endocarditis should be individual, as in a third of patients with PMP, auscultatory signs of valvular regurgitation appear after physical exertion, and may also be intermittent at rest. In addition, patients with PMC without echocardiographic data of mitral regurgitation with signs of thickening and / or an increase in the size of the valve (especially males over 45 years of age) are susceptible to the development of infective endocarditis. When prescribing preventive measures of infective endocarditis, the type and anatomical area of the alleged invasive intervention, the previous history of endocarditis, is also taken into account.

Prognosis of mitral valve prolapse

In most asymptomatic patients with mitral valve prolapse, the prognosis is favorable, but patients with mitral regurgitation are considered to be at high risk of cardiovascular complications and mortality.