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Classic and non-classic forms of mitral valve prolapse/Mitral kapak prolapsinin klasik ve klasik olmayan formlari.

Introduction

Mitral valve prolapse (MVP) is a relatively common (prevalence between 0.6 and 2.4%) (1-4) heart disorder, easily diagnosed nowadays by echocardiography. It is characterized by a systolic billowing of one or both mitral valve leaflets (more than 2 mm) into the left atrium. MVP can be clinically silent or present itself with manifestations such as dizziness, dyspnea, pre-syncope and syncope episodes, as well as thrombo embolic events (strokes) (5-7). It can also be combined with other disorders, such as atrial septal defect (ASD), ventricular septal defect (VSD), Marfan syndrome or Ehlers-Danlos syndrome (8, 9).

An established classification of MVP distinguishes between a classic form, when the above-mentioned billowing is accompanied by a thickening (more than 5 mm) of one or both leaflets, and a non-classic form, when no such thickening is present (2).

In this study, we deal with the characteristics (clinical and demographic) of patients with MVP, mainly focusing on the differences between those with the classic and those with the non-classic form, thus examining the necessity and clinical significance of this distinction.

Methods

We included in this prospective study all patients examined in our preventive cardiology outpatient clinics during the biannual period October 2004-October 2006. We examined in total 10.818 patients, 238 of whom (2.2%) were diagnosed for MVP, based on the echocardiographic diagnostic criterion of systolic billowing of one or both mitral valve leaflets (more than 2 mm) into the left atrium. Exclusion criteria were the diagnoses of heart failure, coronary artery disease, any kind of heart valve disease and chronic obstructive pulmonary disease. Among the patients included in the study, we referred for echocardiography those with family history of mitral valve prolapsed or heart valve disease, heart-related symptomatology or audible heart murmurs.

Echocardiography was performed by the same investigator (I.K). We also noted their demographic (age, gender) and clinical data (symptoms, accompanying disorders). For the patients diagnosed for MVP we focused on the differences between the classic and the non-classic form. We applied a three-year follow-up control for all patients, checking for the occurrence of major complications (stroke, death, submission to surgery) and for the general condition of patients. We did not have any written consent forms signed, as the patients willingly presented for the preventive cardiological control and no diagnostic interventional methods or therapeutic applications were utilized for the study.

Statistical analysis

All analyses were done using SPSS version 11.5 software (SPSS Inc, Chicago, IL, USA).

To compare variables between the groups, we used the Chi-square test for categorical variables and an unpaired Student's t-test for continuous parameters. We used the comparison of percentages for small samples of patients. The threshold for statistical significance was set at a value for p<0.05.

Results

We included in the study 238 patients, 89 with the classic and 149 with the non-classic form, ranging from 6 to 67 years, mean 17.9 [+ or -] 4.1 years. Overall, 211 patients (88.65%) had no knowledge of their disorder and thus our examination set the initial diagnosis. We found significant differences as far as several parameters are concerned. More specifically, patients with classic MVP had a higher female/male ratio (female 68.53% vs. 53.69%, p<0.05) and presented with more frequent symptoms including dizziness, palpitations, pre-syncope episodes (36 patients vs. 32 patients, p<0.01), more documented supraventricular arrhythmias (3 vs. 2, p<0.01), more frequent serious symptoms including syncope episodes, requiring hospitalization (10 vs. 5, p<0.01), more documented ventricular arrhythmias (2 vs. 1, p<0.01), as well as accompanying disorders-including ASD, VSD, Marfan syndrome and Ehlers-Danlos syndrome (8 patients vs 9, p<0.01) than patients with non-classic MVP

In regard to the aforementioned syndrome patients we have to note that they presented with a variety of the expected typical characteristics, more specifically MVP, arachnodactyly, muscular atrophy and ectopia lentis for the Marfan patients, and MVP skin and joint hyperextensibility (8), ectopia lentis and highgraded myopia for the Ehlers-Danlos patients.

The mean age of diagnosis tended to be earlier for patients with the classic form (17.4 years vs. 18.1 years, p<0.05). Patients with the classic form had analogically more frequently audible systolic clicks (28 vs. 30, p<0.01) and more prominent regurgitation (a total of 56 regurgitation crosses vs. 56, p<0.01) than the rest of the patients.

On the contrary, no significant differences were found as far as number of strokes (one vs. two), submissions to surgery (1 vs 2) for mitral regurgitation and deaths (zero) were concerned.

The aforementioned data are depicted in Table 1.

Discussion

Our study recruited prospectively a large sample of patients and was based on a three-year follow-up control pattern. Thus, we consider that the question regarding the clinical significance of the distinction in classic and non-classic form of MVP has been properly addressed. We concluded, that with the exception of certain major complications (stroke, death, submission to surgery), the classic form of MVP is associated with a higher degree of morbidity in comparison to the non-classic form, as this can be expressed through frequency and severity of symptoms, frequency of hospitalization and connection to accompanying disorders, including ASD, VSD, Marfan and Ehlers-Danlos syndrome.

As, to the best of our knowledge, there are no other prospective studies specifically dealing with the issue, we could only find points of agreement with other authors (2, 5-7) regarding the general features of MVP such as prevalence of female gender or variety and complexity of accompanying symptoms (8, 9).

Conclusion

The findings of our study indicate a more serious clinical profile for the classic form of MVP This practically means the need for augmented clinical suspicion for accompanying pathologies in patients of this category, perhaps with the suggestion for more frequent follow-up controls. A planned extension of this study, which through larger intervals of follow-up controls at 5 and 10 years will provide us with more information concerning associated incidents of stroke, submission to surgery or death, will expand our knowledge concerning the overall morbidity of each form of MVP and probably lead us to definite conclusions regarding the handling of these patients.

Conflict of interest: None declared.

References

(1.) Bar H, Siegmund A, Wolf D, Hardt S, Katus HA, Mereles D. Prevalence of asymptomatic mitral valve malformations. Clin Res Cardiol 2009; 98: 305-9. [CrosRef]

(2.) Freed LA, Levy D, Levine RA, Larson MG, Evans JC, Fuller DL, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341: 1-7. [CrosRef]

(3.) Hepner AD, Ahmadi-Kashani M, Movahed MR. The prevalence of mitral valve prolapse in patients undergoing echocardiography for clinical reason. Int J Cardiol 2007; 123: 55-7. [CrosRef]

(4.) Hepner AD, Morrell H, Greaves S, Greaves J, Movahed MR. Prevalence of mitral valvar prolapse in young athletes. Cardiol Young 2008; 18: 402-4. [CrosRef]

(5.) Mutlu H. Role of echocardiography in mitral valve prolapse. Anadolu Kardiyol Derg 2001; 1: 206-9.

(6.) Avierinos JF, Brown RD, Foley DA, Nkomo V, Petty GW, Scott C, et al. Cerebral ischemic events after diagnosis of mitral valve prolapse: a community-based study of incidence and predictive factors. Stroke 2003; 34: 1339-44. [CrosRef]

(7.) Cetinkaya M, Semizel E, Bostan O, Cil E. Risk of vasovagal syncope and cardiac arrhythmias in children with mitral valve prolapse. Acta Cardiol 2008; 63: 395-8. [CrosRef]

(8.) Freed LA, Benjamin EJ, Levy D, Larson MG, Evans JC, Fuller DL, et al. "Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study". J Am Coll Cardiol 2002; 40: 1298-304. [CrosRef]

(9.) Cavenaghi S, Marino LH, Oliveira PIP Lamari NM. Joint hypermobility in patients with mitral valve prolapse. Arq Bras Cardiol 2009; 93: 307-11.

Georgios I. Tagarakis, Ioannis Karantzis [1], Fani Tsolaki, Georgios E. Stylianakis [1], Marios E. Daskalopoulos, Nikolaos B. Tsilimingas

Department of Cardiovascular and Thoracic Surgery, University Hospital of Thessaly, Larissa

[1] Department of Cardiology, General Hospital of Kozani, Kozani city-Greece

Address for Correspondence/Yazisma Adresi: Georgios I. Tagarakis, MD, PhD, Anaximandrou 24, 54250, Thessaloniki-Greece Phone: 00306970806717 Fax: 00302310912645 E-mail: gtagarakis@hotmail.com

Accepted Date/Kabul Tarihi: 09.05.2011 Available Online Date/Cevrimici Yayin Tarihi: 04.01.2012

doi: 10.5152/akd.2012.001
Table 1. Demographic and clinical characteristics of patients with
classic and non-classic forms of MVP

Variables Classic Non-classic p *
 form (n=89) form (n=149)

Gender, female, n (%) 61 (68.53) 80 (53.69) <0.05
Age of diagnosis, 17.4 [+ or -] 3.9 18.1 [+ or -] 4.0 <0.05
 years
Symptoms, n (%) 36 (40.44) 32 (21.47) <0.01
 (dizziness,
 palpitations)
Serious symptoms, 10 (11.23) 5 (3.35) <0.01
 requiring
 hospitalization,
 n (%)
Supraventricular 3 2 <0.01
 arrhythmias, n
Ventricular 2 1 <0.01
 arrhythmias, n
Accompanying 8 (8.98) 9 (6.04) <0.01
 disorders, n (%)
ASD, n 5
VSD, n 1 7
Marfan syndrome, n 1 1
Ehler-Danlos 1 -
 syndrome, n
Systolic click, n 28 30 <0.01
** Mitral valve 56+ 56+ <0.01
 regurgitation
Stroke, n 1 2 NS
Submission to 1 2 NS
 surgery for mitral
 insufficiency, n
Deaths, n 0 0 NS

Data are presented as mean [+ or -] SD, numbers and percentages

* Chi-square and unpaired Student's t test

** The degree of mitral regurgitation was expressed in crosses (+) and
measured additively
within each group

ASD--atrial septal defect, MVP--mitral valve prolapse, VSD--ventricular
septal defect
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Article Details
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Title Annotation:Original Investigation/Ozgun Arastirma
Author:Tagarakis, Georgios I.; Karantzis, Ioannis; Tsolaki, Fani; Stylianakis, Georgios E.; Daskalopoulos,
Publication:The Anatolian Journal of Cardiology (Anadolu Kardiyoloji Dergisi)
Article Type:Clinical report
Date:Feb 1, 2012
Words:1561
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