Comparison of auscultation with two-dimensional and Doppler echocardiography in patients with suspected mitral valve prolapse

Mitral Valve Prolapse and Its Motley Crew-Syndromic Prevalence, Pathophysiology, and Progression of a Common Heart Condition

Mitral valve prolapse (MVP) is a commonly occurring heart condition defined by enlargement and superior displacement of the mitral valve leaflet(s) during systole. Although commonly seen as a standalone disorder, MVP has also been described in case reports and small studies of patients with various genetic syndromes. In this review, we analyzed the prevalence of MVP within syndromes where an association to MVP has previously been reported. We further discussed the shared biological pathways that cause MVP in these syndromes, as well as how MVP in turn causes a diverse array of cardiac and noncardiac complications. We found 105 studies that identified patients with mitral valve anomalies within 18 different genetic, developmental, and connective tissue diseases. We show that some disorders previously believed to have an increased prevalence of MVP, including osteogenesis imperfecta, fragile X syndrome, Down syndrome, and Pseudoxanthoma elasticum, have few to no studies that use up-to-date diagnostic criteria for the disease and therefore may be overestimating the prevalence of MVP within the syndrome. Additionally, we highlight that in contrast to early studies describing MVP as a benign entity, the clinical course experienced by patients can be heterogeneous and may cause significant cardiovascular morbidity and mortality. Currently only surgical correction of MVP is curative, but it is reserved for severe cases in which irreversible complications of MVP may already be established; therefore, a review of clinical guidelines to allow for earlier surgical intervention may be warranted to lower cardiovascular risk in patients with MVP.

Echocardiographic screening for mitral valve prolapse in Turkish school children

We determined the frequency of mitral valve prolapse (MVP) in healthy Turkish school children using the current echocardiographic diagnostic criteria. This epidemiological survey was performed on 2550 school children. All children were screened with echocardiography and the family of children with MVP were also screened. The prolapse of mitral leaflets into left atrium ≥ 2 mm in parasternal long-axis view was used as diagnostic criteria. MVP was classified as classical or non-classical according to anterior mitral leaflet thickness. The thickness of anterior mitral leaflet, the extent of prolapse, and the presence of mitral regurgitation were evaluated. The children were also questioned about the associated symptoms. The prevalence of MVP was 1.25% in children with a mean age of 11.1 ± 2.9 years. The prevalence was 0.9%, 1.2%, and 1.6% in 5-9 years, 10-13 years, and 14-18 years of age, respectively. 43.7% of the cases were classical MVP. The frequency of auscultation findings was 34.3%. 11/34 children had mitral regurgitation. There was no statistically significant difference between classical MVP and non-classical MVP in terms of mitral regurgitation, physical examination findings, and symptoms. Anxiety (37.5%) was the most common symptom. The frequency of MVP in the first-degree relatives of children with MVP was 11/84 (13.1%). Most patients with MVP don't have auscultation findings and symptoms, therefore echocardiography is an important tool in the diagnosis of MVP. It is also reasonable to screen first degree relatives of MVP patients with echocardiography.

Effect of teaching and type of stethoscope on cardiac auscultatory performance

BACKGROUND

Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope.

METHODS

This study was a randomized trial with a 2 x 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation.

RESULTS

Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The kappa values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such.

CONCLUSION

Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.

The clinical impact of echocardiography on antibiotic prophylaxis use in patients with suspected mitral valve prolapse

PURPOSE

To determine the impact of echocardiography on the use of antibiotic prophylaxis in patients with suspected mitral valve prolapse (MVP).

PATIENTS AND METHODS

We evaluated 147 consecutive patients who were referred for "rule out mitral valve prolapse" to a university hospital echocardiography laboratory. Chart review and phone contact were used to determine the demographic characteristics of the patients; past diagnosis of MVP, symptoms, and exam at referral; practice specialty of referring MD; echocardiographic findings; and change in prophylaxis usage as a result of the echocardiogram (ECHO). Prophylaxis was considered to be indicated if the echocardiogram demonstrated MVP with at least mild regurgitation or abnormal thickening of at least one mitral leaflet.

RESULTS

Based on the ECHO a change in antibiotic prophylaxis was indicated in 20 of 147 (14%) patients including initiation of prophylaxis in 6, and discontinuation of prophylaxis in 14. However, only 4 of 20 patients (20%) actually changed their prophylaxis habits leading to an actual yield of 4 management changes per 131 ECHOs ordered (3%). This corresponded to 1 change in management per $36,250 in hospital and physician costs. Younger age, female gender, and presence of symptoms were associated with a benign ECHO. Indications for a change in management were not significantly different between physician specialities: 18% for generalists (internal medicine and family practice), 12% for cardiologists, and 7% for other specialists, P = 0.3.

CONCLUSIONS

In patients referred for evaluation of MVP, echocardiography infrequently resulted in changes in antibiotic prophylaxis management and was associated with significant expense.

Anatomic explanation of mobile systolic clicks: implications for the clinical and echocardiographic diagnosis of mitral valve prolapse

An echocardiogram (echo) is often ordered for suspected mitral valve prolapse (MVP). Using echo as the gold standard, we conducted a meticulous physical examination on 61 patients with this referral diagnosis. Ninety percent of patients with negative physical examination and echo results for MVP had physical examination findings likely to have been misinterpreted as MVP by the referring physician. Redundant portions of the mitral valve apparatus were found in 57% of patients with MVP on our physical examination but not on echo. A carefully performed physical examination (including dynamic auscultation) can exclude MVP. Not all mobile systolic clicks are associated with anatomic echo prolapse; they can be generated by redundant chordae tendineae and, in the absence of echo prolapse, probably by redundant leaflets. Patients with mobile systolic clicks should have an echo to determine the portion of the spectrum of echo prolapse present and to determine risk stratification and management.

A decision aid for referring patients with systolic murmurs for echocardiography

OBJECTIVE

To describe the practice pattern of a group of primary care providers in ordering echocardiography for healthy patients and to derive a decision aid to identify patients with systolic murmurs who have significant cardiac lesions.

DESIGN

Retrospective case review of clinical variables, including the demographic, historical, and physical examination features obtained from chart review of the physician evaluation prior to referral for echocardiography and the echocardiographic results, with both univariate and multivariate regression analyses used to identify variables predictive of positive echocardiographic outcomes and to derive a regression model.

SETTING

General internal medicine clinic in an urban major teaching hospital.

PATIENTS/PARTICIPANTS

169 patients between the ages of 18 and 55 years selected retrospectively from medical records.

MEASUREMENTS AND MAIN RESULTS

Symptoms and auscultatory findings were not predictive of positive echocardiographic outcomes among the patients referred for the test. For the patients who had systolic murmurs, a logistic regression model had three significant predictors of positive echocardiographic results: additional year of age (odds ratio: 1.08, 95% CI: 1.02-1.13; p = 0.007); male gender (odds ratio: 5.87, 95% CI: 1.99-17.3; p = 0.002); and murmur grade > or = 3 (odds ratio: 4.99, 95% CI: 1.27-19.6; p = 0.02). The receiver-operating characteristic (ROC) curve area for this model was 0.741. If women aged 35 years and less with murmur grades < or = 2 had not been referred, 47% of the echocardiographies could have been avoided while retaining a sensitivity of 90%.

CONCLUSIONS

The study suggested that healthy patients with systolic murmurs are least likely to have positive echocardiographic results when they are young and female and have murmur grades < or = 2. More careful screening of this group might make unnecessary almost half of the echocardiographies yielding negative results ordered for healthy patients with systolic murmurs.

Mitral valve prolapse and body habitus in children

Mitral valve prolapse has generally been associated in adults with a thin body habitus. However, prior studies used biased samples or limited anthropometric measures. In addition, no information has been available on the subjective assessment of body habitus and diagnosis of mitral valve prolapse, especially in children. We conducted a cross-sectional study on 813 children with uniform assessment of anthropometric measures and mitral valve prolapse. Consistent with research conducted on adults, those subjects with mitral valve prolapse were lighter, thinner, and had, on average, lower values for several, quantifiable anthropometric parameters with the exception of height. However, the subjective assessment showed that while the assessment did not differ by diagnosis, those subjects with mitral valve prolapse were never described as fat. These data support an association between mitral valve prolapse and slender body habitus and extends it to children, thus underscoring the clinical importance that a thin body habitus may be a marker for mitral valve prolapse throughout the age span. This association may partly explain the observed genetic distribution of mitral valve prolapse.

Use of auscultation to follow patients with mitral systolic clicks and murmurs

Mitral systolic clicks and murmurs together with associated symptoms constitute a major reason for cardiologic referral. Although echocardiography with Doppler study enables characterization of the mitral valve apparatus and quantification of regurgitation, its use has resulted in an overemphasis of the technical diagnosis of mitral valve prolapse and an undervaluation of diagnosis based on physical examination. To determine the clinical significance of an auscultatory classification of mitral systolic clicks with or without precordial systolic murmurs, 1 consultant's medical records of 291 patients with these signs were reviewed. Based on initial auscultatory findings, patients were divided into: (1) single or multiple apical systolic clicks with no murmur (n = 99); (2) single or multiple apical systolic clicks and a late systolic murmur (n = 129); and (3) single or multiple apical clicks and an apical pansystolic murmur or murmur beginning in the first half of systole (n = 63). The average duration of patient follow-up was 8 years (range 1 to 30). The prognosis was excellent for patients from all 3 classes. Two cardiac-related deaths occurred: 1 each from classes 1 and 2. Mitral valve surgery was performed in 3 class 2 patients (2%) and in 2 class 3 patients (3%). No patients developed endocarditis during follow-up. Palpitations, with varying anxiety overlay, constituted a major indication for cardiologic referral in all 3 classes. Auscultatory findings were valuable to the physician for explanation and relief of patient anxiety. For patient management, use of an auscultatory classification may be preferable to the technically generated term "mitral valve prolapse."

Mitral valve prolapse. When is it serious?

Mitral valve prolapse can best be diagnosed with careful clinical evaluation, including dynamic auscultation. Treatment consists of reassurance, pharmacotherapy for troublesome symptoms, and careful monitoring for signs of complications. Most complications can be either prevented or treated.

The natural history of unexpected Doppler mitral regurgitation

It is common for patients to be diagnosed as having valvular regurgitation by Doppler echo when no such murmur has been heard by the referring clinician. To test the hypothesis that such patients have clinically unimportant heart disease, the authors evaluated the records of 213 consecutive men in whom mitral regurgitation had been found by pulsed Doppler. In 95 patients (group I) mitral regurgitation was audible, whereas in the other 118, it was not. In 97 patients with inaudible mitral regurgitation there were no structural mitral valve abnormalities by 2D echo. This group of 97 patients (group II) was defined as having unexpected Doppler mitral regurgitation. In group II patients there was a high prevalence of hypertension (50%), congestive heart failure (44%), alcohol abuse (46%), diabetes (27%), coronary artery disease (63%), and atrial fibrillation (13%). The following variables were distributed similarly in groups I and II: survival time, age, presence of congestive heart failure or coronary artery disease, left ventricular short-axis end diastolic and end systolic dimensions, E point septal separation, and the severity of dyssynergy. Atrial fibrillation was more common in group I (p = 0.017), and group I patients had a higher Quetelet's Index (weight/height squared) (p = 0.03). In group II, the factors most closely related to survival were the presence of dyssynergy, of atrial fibrillation, or of congestive heart failure. Although no group II patient had endocarditis or required mitral valve replacement, their survival was markedly decreased compared with people of similar age in the general population. The majority of cardiogenic deaths in group II patients were due to coronary artery disease.(ABSTRACT TRUNCATED AT 250 WORDS)