Updated: 3/28/2020

Mitral Valve Prolapse

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Snapshot
  • A 30-year-old woman presents to her first primary care appointment. She says she experiences episodes of mild shortness of breath and palpitations; however, it does not impair her activities of daily living. She is otherwise healthy. On physical exam, a systolic murmur with a mid-systolic click is noted in the 5th intercostal space at the mid-clavicular line. Preparations are made to undergo an echocardiogram.
Introduction
  • Clinical definition
    • disease of the mitral valve characterized by superior displacement and thickening of the mitral leaflets
  • Epidemiology
    • demographics
      • female > male
      • middle-aged adults
      • mitral valve prolapse is the most frequent valvular lesion
    • location
      • mitral valve
  • Etiology
    • myxomatous degeneration
      • can be spontaneous or secondary to a connective tissue disorder
    • rheumatic fever
    • myocardial infarction
    • chordae rupture
    • idiopathic
  • Pathogenesis 
    • myxomatous degeneration of the mitral valve
      • valvular leaflets become abnormal secondary to
        • excessive degradation of collagen and elastin by proteolytic enzymes
        • accumulation of proteoglycans
      • the chordae tendinae become weakened and elongated
      • annular dilation of the mitral valve
    • connective tissue disorder
      • deficiency in collagen, elastin, and proteoglycans cause leaflets to be mostly thin and translucent
  • Associated conditions
    • Marfan syndrome
    • Ehlers-Danlos syndrome
    • polycystic kidney disease
    • fragile X syndrome
  • Prognosis
    • progressive with age
    • patients are susceptible to infective endocarditis
Presentation
  • Symptoms
    • palpitations
    • chest pain, regardless of exertion
    • shortness of breath
  • Physical exam  
    • systolic murmur 
      • high-pitched late systolic crescendo murmur
      • midsystolic click from tensing of the chordae tendinae
      • loudest over the apex
      • murmur becomes softer with squatting
      • murmur becomes louder with standing, Valsalva maneuver, and nitrate administration
Imaging
  • Echocardiography
    • indication
      • confirms the diagnosis
      • rule out other valvular abnormalities
    • findings
      • superior displacement of mitral leaflets
Studies
  • Making the diagnosis
    • based on clinical presentation and echocardiography
Differential
  • Atrial myxoma
    • distinguishing factor
      • while this can also present with a systolic click, echocardiography will show mass in the atria
Murmurs
Systolic Murmurs
Diastolic Murmurs
  • Aortic stenosis
  • Mitral regurgitation
  • Tricuspid regurgitation
  • Aortic regurgitation
  • Mitral stenosis
Treatment
  • Management approach
    • if patients do not have mitral regurgitation, treatment is typically not warranted
    • prophylaxis is not warranted for endocarditis or thromboembolism
  • Operative
    • mitral valve replacement or repair
      • indication
        • mitral valve prolapse with mitral regurgitation
Complications
  • Mitral regurgitation
  • Chorda tendinae rupture
  • Infective endocarditis

 

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Questions (2)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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Topic COMMENTS (5)
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