Radiographic appearance of the thorax in systolic click-late systolic murmur syndrome

Influence of Morphometry on Echocardiographic Measurements in Cavalier King Charles Spaniels: An Inverse Probability Weighting Analysis

The development and progression of myxomatous mitral valve disease (MMVD) in Cavalier King Charles Spaniels (CKCS) are difficult to predict. Thus, the identification of dogs with a morphotype associated with more severe mitral disease at a young age is desirable. The aims of this study were to: (1) describe the physical, morphometric, and echocardiographic features of class B1 MMVD-affected Cavalier King Charles Spaniels (CKCS) according to the American College of Veterinary Internal Medicine (ACVIM) guidelines; (2) evaluate the influence of morphometric physical measurements on murmur intensity, mitral valve prolapse (MVP), regurgitant jet size, and indexed mitral valve and annulus measurements. Fifty-two MMVD-affected CKCS were included in the ACVIM class B1. This is a prospective clinical cross-sectional study. Morphometric measurements, which included the body, thorax, and head sizes of each dog, were investigated to establish the association with heart murmur intensity, valvular and annular echocardiographic measurements, MVP, and regurgitant jet size, using inverse probability weighting (IPW) analyses to adjust for confounding. The IPW analyses showed that when the head length and nose length decreased, dogs had a more severe regurgitant jet size. Furthermore, subjects with a more pronounced head stop angle had thicker anterior mitral valve leaflets. A brachycephalic morphotype, as seen in dogs similar to the King Charles Spaniel breed in terms of cephalic morphology, is associated with a more severe regurgitant jet size and with valvular characteristics that are related to the most severe forms of MMVD.

A mechanism of a cardiac murmur with respiratory variation in a patient with straight back syndrome

A 20-year-old male without any symptoms was referred for heart murmur on a medical examination. A thrill was palpable at the upper left sternal border. His cardiac murmur showed respiratory variation. The systolic murmur was louder (Levine grade IV/VI) during expiration and diminished during inspiration (Levine grade I/VI). He was thin and had a narrow thoracic cage in the anteroposterior direction due to straight back syndrome (SBS). An echocardiogram and a right ventriculogram showed changes in the diameter of the right ventricular outflow tract (RVOT) on respiration. During expiration, the RVOT was compressed and narrow, while it was expanded during inspiration. Cardiac catheterization demonstrated a 10-mmHg of pressure gradient across the RVOT during expiration but no pressure gradient during inspiration. Thus, respiratory compression to the RVOT by a narrow thoracic cage due to SBS was the cause of the cardiac murmur with respiratory alterations. Our case highlights the importance of physical examination, including an inspection of the patient's physique. <Learning objective: When examining a patient with a cardiac murmur, respiratory alterations of cardiac murmurs should be auscultated. In these cases, straight back syndrome would be one of the differential diagnoses and should be considered. During a physical examination, inspection of the patient's physique is also important.>.

A Population-Based Study of Healthcare Resource Utilization in Patients with Mitral Valve Prolapse

This study investigated differences in the utilization of healthcare services between subjects with mitral valve prolapse (MVP) and comparison subjects using data from Taiwan's National Health Insurance population-based database, 138,493 patients with MVP (study group) and 138,493 matched patients without MVP (comparison group). We calculated the utilization of healthcare services in the year 2016 for each study sample. Patients with MVP had more outpatient cardiological services during the year (5.3 vs. 0.7, p < 0.001) and higher outpatient cardiology costs (US$226.0 vs. US$30.8, p < 0.001) than patients without MVP. As expected, patients with MVP had a longer inpatient stay (0.5 vs. 0.1, p < 0.001) and higher inpatients costs (US$158.0 vs. US$22.9, p < 0.001) than patients without MVP for cardiology services. Furthermore, patients with MVP also had more outpatient non-cardiology services (20.8 vs. 16.5, p < 0.001) and associated costs (US$708.3 vs. US$518.7, p < 0.001) than patients without MVP in the year 2016. Multiple regression analysis indicated that patients with MVP had higher total costs for all healthcare services than patients without MVP after adjusting for the urbanization level, monthly income, and geographic region. This study demonstrated that healthcare utilization by patients with MVP is substantially higher than comparison patients. Future studies are encouraged to explore MVP treatment with less expensive modalities while maintaining care quality and without jeopardizing patient outcomes.

Incidence and Risk Factors of Cardiac Abnormalities in Patients with Idiopathic Scoliosis

OBJECTIVE

We sought to investigate the incidence of cardiac abnormalities in patients with idiopathic scoliosis and identify risk factors related to cardiac abnormalities.

METHODS

A cohort of 531 patients with idiopathic scoliosis requiring surgical treatment in our hospital from March 2009 to August 2017 were recorded. Clinical data including medical records, radiograph, and echocardiogram were collected. All patients were divided into groups: control, congenital heart disease (CHD), and other cardiac abnormalities (OCAs). The incidence and related factors for cardiac abnormalities were analyzed.

RESULTS

The age of the study cohort was 17.8 ± 7.3 years. The average Cobb angle was 57.7 ± 16.5 degrees. Cardiac abnormalities were found in 149 (28.06%) patients, including 22 (4.14%) with CHD and 127 (23.92%) with OCAs. Atrial septal defect was the most common CHD with an incidence of 1.13% (6 of 531). Mitral valve prolapse was detected in 62 (11.68%) patients, which was the most prevalent OCA. Patients with CHD or OCAs weighed less as compared with patients without cardiac abnormalities. Low height was associated with CHD in patients with idiopathic scoliosis. Six patients with severe cardiac abnormalities must undergo cardiac intervention before scoliosis surgery.

CONCLUSIONS

The overall incidence of cardiac abnormalities was 28.81% in patients with idiopathic scoliosis. An echocardiogram may be helpful as a preoperative examination for patients with idiopathic scoliosis before scoliosis surgery.

Characteristics of mitral valve leaflet length in patients with pectus excavatum: A single center cross-sectional study

The mitral valve morphology in patients with pectus excavatum (PE) has not been fully investigated. Thirty-five patients with PE, 46 normal controls, and patients with hypertrophic cardiomyopathy (HCM) who underwent 2 leaflet length measurements of Carpentier classification P2 and A2 using a transthoracic echocardiography were retrospectively investigated. The coaptation lengths and depths, papillary muscle tethering length, and mitral annular diameters were also measured. The P2 and A2 lengths were separately compared between 2 groups: older than 16 years and 16 years or younger. Furthermore, the correlations between actual P2 or A2 lengths and Haller computed tomography index, an index of chest deformity, were investigated in patients with PE exclusively. Among subjects older than 16 years, patients with PE had significantly shorter P2, longer A2, shorter copatation depth, and longer papillary muscle tethering length compared with normal controls. Similarly, patients with PE had significantly shorter P2 and shorter coaptation depth even compared with patients with HCM, while no significant difference was found in A2 length and papillary muscle tethering length. The same tendency was noted between 4 normal controls and 7 age- and sex-matched patients with PE ≤ 16 years old. No significant difference regarding A2/P2 ratio was found between patients with PE older and younger than 16 years. No significant correlation between the Haller computed tomography index and actual mitral leaflet lengths in patients with PE older than 16 years was noted; the same was observed for A2/P2 in all patients with PE. In conclusion, the characteristic features of the shorter posterior mitral leaflet, the longer anterior mitral leaflet, the shorter coaptation depth, and the longer papillary muscle tethering length in patients with PE was demonstrated. This finding might provide a clue regarding the etiology of mitral valve prolapse in PE at its possible earliest form.

Rigid spine syndrome: a noninvasive cardiac evaluation

Rigid spine syndrome (RSS) is a group of childhood-onset muscle disorders characterized by marked limitation of flexion of the spine. Various cardiac changes have been documented in case reports. This study reports on a cardiac evaluation of nine patients with the "vacuolar variant" of RSS. Noninvasive cardiac evaluation entailed creatine kinase levels, full-inspiration chest roentgenograms, standard 12-lead ECG, and 24-h ambulatory ECG recording, as well as M-mode and two-dimensional echocardiography with Doppler study. Heart auscultation was abnormal in five patients. Creatine kinase MB fraction was normal in all patients. Chest roentgenogram showed scoliosis (five of nine), kyphosis (one of nine), severe anterior-posterior flattening of the chest cavity (two of nine), elevated hemidiaphragm (one of nine), caved-in appearance of upper lobes (two of nine), and symmetry of lung volumes (one of nine). Twelve-lead ECG abnormalities indicated right-sided heart disease (three of nine). Echocardiogram showed mitral valve prolapse (five of nine) with regurgitation (three of five) and evidence of pulmonary hypertension (three of nine). Ambulatory ECG recorded paroxysmal tachyarrhythmias in hypoxic or hypercapnic patients (three of nine). There was no correlation between any cardiac abnormalities and patient weakness. Mitral prolapse/regurgitation may have a developmental association with this congenital myopathy. Findings of cor pulmonale were due to the restrictive chest wall defect and respiratory muscle weakness. Paroxysmal tachyarrhythmias were due to hypoxia or hypercapnia. There was no evidence of a primary cardiomyopathy.

The genetics of mitral valve prolapse

Mitral valve prolapse (MVP) is a very common clinical condition that refers to a systolic billowing of one or both mitral valve leaflets into the left atrium. Improvements of echocardiographic techniques and new insights in mitral valve anatomy and physiology have rendered the diagnosis of this condition more accurate and reliable. MVP can be sporadic or familial, demonstrating autosomal dominant and X-linked inheritance. Three different loci on chromosomes 16, 11 and 13 have been found to be linked to MVP, but no specific gene has been described. Another locus on chromosome X was found to cosegregate with a rare form of MVP called 'X-linked myxomatous valvular dystrophy'. MVP is more frequent in patients with connective tissue disorders including Marfan syndrome, Ehlers-Danlos and osteogenesis imperfecta. The purpose of this review is to describe previous studies on the genetics and prevalence of MVP. The report warrants the need for further genetically based studies on this common, albeit not fully understood, clinical entity.

The relationship between echocardiographic features of mitral valve and elastic properties of aortic wall and Beighton hypermobility score in patients with mitral valve prolapse

The present study was designed to investigate the incidence of benign joint hypermobility syndrome (BJHMS) in mitral valve prolapse (MVP) and the correlation between the echocardiographic features of the mitral valve and elastic properties of the aortic wall and Beighton hypermobility score (BHS) in patients with MVP and BJHMS. Fourty-six patients with nonrheumatic, uncomplicated, and isolated mitral anterior leaflet prolapse (7 men and 39 women, mean age; 26.1 +/- 5.9) and 25 healthy subjects (3 men and 22 women, mean age, 25.4 +/- 4.3) were studied. Patients were divided into two groups according to their BHS (group I, MVP+BJHMS; group II, MVP-BJHMS). Individuals with accompanying cardiac or systemic disease were excluded. Echocardiographic examination was performed in all subjects. The presence of BJHMS was evaluated according to Beighton's criteria. The incidence of BJHMS in patients with MVP was found to be significantly higher than that of controls (45.6%, (21/46) vs 12% (3/25), P < 0.0001). Group I (MVP + BJHMS) had significantly increased anterior mitral leaflet thickness (AMLT, 3.4 +/- 0.4 vs 3.1 +/- 0.3; P < 0.005), maximal leaflet displacement (MLD, 2.4 +/- 0.4 vs 1.7 +/- 0.4; P < 0.005), and degree of mitral regurgitation (DMR, 17.1 +/- 7.2 vs 11.2 +/- 4.4; P < 0.01) compared to group II. However, the index of aortic stiffness (IAOS) was found to be lower (17.6 +/- 6.9 vs 23.9 +/- 7.6; P < 0.005) and aortic distensibility (AOD) to be higher (0.0035 +/- 0.007 vs 0.0024 +/- 0.005; P < 0.005) in group I. There was a significant correlation between AMLT, MLD and DMR, and BHS (r = 0.57/P = 0.007, r = 0.55/P < 0.009, r = 0.51/P < 0.01, respectively). In addition, AOD correlated positively with BHS (r = 0.53/P < 0.005), but the index of aortic stiffness correlated inversely with BHS (r = -0.49/P < 0.007). The incidence of BJHMS in patients with MVP was more frequent than the normal population and there was a significant correlation between the severity of BJHMS (according to BHS) and echocardiographic features of the mitral leaflets and elastic properties of the aortic wall.

Host susceptibility factors in mycobacterial infection. Genetics and body morphotype

Through identification and evaluation of mutations and polymorphisms in components of the IFN gamma response pathways, a better understanding of the mechanisms and risk factors influencing the development of mycobacterial disease is gained. This may lead the way for development of therapeutic and preventative strategies. Although conventional science has focused on identifying discrete mutations, greater awareness of the impact of subtle changes, both at the genetic (polymorphisms) and physical levels (body morphotype), may prove critical in the investigative process. There has been extraordinary progress in the understanding of mycobacterial susceptibility factors over the last few years. The recognition of characteristic phenotypes will lead to the identification of new genetic bases for disease.

Clinical spectrum of skeletal abnormalities and mitral valve prolapse and their clinical implications

Fifty-six patients were diagnosed to have mitral valve prolapse (MVP) syndrome by auscultatory criteria, confirmed by cross-sectional echocardiography. Complete physical examination and x-ray of the bony thorax revealed bony deformities which were subdivided into four main groups according to the predominant deformity. Shallow chest with pectus excavatum, straight back, kyphoscoliosis and elliptical chest in marfanoid patients were reported in the cases studied. It is concluded that musculoskeletal abnormalities have to be considered as nonauscultatory features of MVP. Therefore, any patient with musculoskeletal deformity has to be screened for MVP by cross-sectional echocardiography to prevent life-threatening complications.

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.

Mild dehydration induces echocardiographic signs of mitral valve prolapse in healthy females with prior normal cardiac findings

This study was designed to investigate the hypothesis that mitral valve prolapse (MVP) can be induced after diuresis in women without the abnormality who have characteristic body habitus. Fifteen tall, slim, healthy female volunteers with a normal cardiac findings, echocardiogram, and history were investigated after mild diuresis with furosemide and after placebo. All subjects lost weight after furosemide and placebo administration; but mean weight loss was significantly greater after furosemide administration than after placebo administration. Echocardiography showed MVP in none of the 15 patients before treatment, in seven after administration of placebo, and in seven after administration of furosemide. Coaptation point prolapsed superior to the anulus in seven subjects with echocardiographically determined MVP. Left ventricular end-diastolic dimensions decreased significantly after placebo or furosemide administration in subjects in whom MVP developed compared with the measurement in those in whom MVP did not develop. Murmurs characteristic of MVP disappeared in all four rehydrated subjects and echocardiographic changes resolved in two of the five rehydrated subjects. Thus echocardiographically determined MVP can be induced by mild dehydration in women with phenotypic body habitus of MVP; changes may resolve with rehydration. Results suggest an explanation for variable physical examination findings in persons with MVP.

Echocardiographic evaluation of the aortic root and mitral valve in children and adolescents with isolated pectus excavatum: comparison with Marfan patients

Pectus excavatum, mitral valve prolapse (MVP), and dilated aortic root occur frequently in patients with Marfan's syndrome (MS). Patients with isolated pectus excavatum (IPE) have a high prevalence of MVP, but it is not known whether aortic root dilatation is a risk in those patients. To test the hypothesis that IPE and MS represent a spectrum of connective tissue dystrophy with MV and aortic root involvement, two-dimensional (2D) echocardiography was used to measure the aortic root diameter and assess for MVP in IPE (n = 31), MS (n = 14), and normal (n = 16) gender- and age-matched patients. Aortic root was measured in parasternal long- and short-axis views, just above the aortic sinuses, at end systole, in six cardiac cycles, and averaged. Parasternal long-axis view was used to assess for MVP. Aortic root diameter in IPE patients was not different from that in normal subjects, 24 +/- 4 mm vs 22 +/- 4 mm (p = NS), respectively, both were significantly smaller than that in MS patients (30 +/- 5 mm; p less than 0.05). MVP was present in 17 of 31 (55%) IPE patients vs 12 of 14 (86%) MS patients (p = NS) and in only 1 of 16 (6%) normal subjects (p less than 0.05) vs both IPE and MS. We conclude that young patients with IPE represent an isolated form of connective tissue abnormality because of the presence of pectus excavatum and MVP, but this is different from the systemic involvement of MS because of the lack of other systemic findings, including aortic root dilatation and changes in body habitus.

Comparison of cardiovascular and skeletal features of primary mitral valve prolapse and Marfan syndrome

The association of primary mitral valve prolapse (MVP) with thoracic bony abnormalities has led to the suggestion that MVP may be a forme fruste of the Marfan syndrome. Echocardiographic, skeletal and anthropometric findings in 59 subjects with primary MVP and 59 age- and sex-matched patients with Marfan syndrome were compared with those in 59 control subjects. Subjects with mitral prolapse were similar to control subjects and differed (p less than 0.025 to p less than 0.001) from the patients with Marfan syndrome in aortic root dimensions, height, arm span, upper/lower segment ratio and prevalences of arachnodactyly, scoliosis and pectus carinatum. Subjects with mitral prolapse and patients with Marfan syndrome had similar body mass indexes and prevalences of pectus excavatum and straight back. All 3 groups were similar in arm span/height ratio. The 5 subjects with MVP and arachnodactyly had lower weights, smaller body surface areas and smaller aortic root dimensions, and were more likely to have scoliosis than subjects with MVP without arachnodactyly. Thus, primary MVP differs from the Marfan syndrome in all major skeletal and cardiovascular features.

Mitral valve prolapse

Mitral valve prolapse is a common mitral valve disorder manifested clinically as a midsystolic click and/or a late systolic murmur (the click-murmur syndrome) and pathologically as billowing or prolapsing mitral leaflets (the floppy valve syndrome). Not only is it one of the two most common congenital heart diseases and the most common valve disorder diagnosed in the United States, but it is also prevalent throughout the world. Mitral valve prolapse may be associated with a variety of other conditions or diseases. Diagnosis of mitral valve prolapse should be made on clinical grounds and, if necessary, supported by echocardiography. The majority of patients with mitral valve prolapse suffer no serious sequelae. However, major complications such as disabling angina-like chest pains, progressive mitral regurgitation, infective endocarditis, thromboembolism, serious arrhythmias, and sudden death may occur. Unless these serious complications occur, most of the patients with mitral valve prolapse need no treatment other than reassurance, including those with atypical chest pain or palpitation unconfirmed by objective data. Therapy with a beta-blocker for disabling chest pain and/or arrhythmias and antiplatelet therapy for cerebral embolic events may be indicated. In occasional patients with significant mitral regurgitation surgery may be necessary.

Relation between clinical features of the mitral prolapse syndrome and echocardiographically documented mitral valve prolapse

Mitral valve prolapse, the most common inherited cardiovascular condition, has been associated with a variety of signs, symptoms and electrocardiographic abnormalities, but the true spectrum of the mitral prolapse syndrome remains in doubt because clinical findings often contribute to patient identification and their prevalence in patient groups may be overstated because of ascertainment bias. Accordingly, clinical findings in 88 patients with echocardiographic mitral prolapse were compared with those in 81 of their adult first degree relatives with mitral prolapse (a group free of ascertainment bias) and in two control groups without mitral prolapse: 172 first degree relatives and 60 spouses. Comparison of relatives with and without mitral prolapse demonstrated true associations between mitral prolapse and clicks or murmurs, or both (67 versus 9%, p less than 0.001), thoracic bony abnormalities (41 versus 16%, p less than 0.001), systolic blood pressure less than 120 mm Hg (53 versus 31%, p less than 0.001), body weight 90% or less of ideal (31 versus 14%, p less than 0.005) and palpitation (40 versus 24%, p less than 0.01). In contrast, relatives with mitral prolapse showed no significant increase over normal relatives or spouses without mitral prolapse in prevalence of chest pain, dyspnea, panic attacks, high anxiety or repolarization abnormalities, but these features were all more common in women than in men (p less than 0.01 to less than 0.001). Thus, the true spectrum of the mitral prolapse syndrome encompasses a midsystolic click and late systolic murmur, thoracic bony abnormalities, low body weight and blood pressure and palpitation. Other suggested clinical features, including nonanginal chest pain, dyspnea, panic attacks and electrocardiographic abnormalities, have appeared to be associated with mitral valve prolapse because of ascertainment bias and an erroneous classification of differences between men and women as being due to mitral valve prolapse.

Mitral valve prolapse in craniofacial skeletal deformities

Mitral valve prolapse is a manifestation of a diffuse connective tissue disorder resulting from mesenchymal dysplasia, and it may have an increased association with orthognathic craniofacial deformities. Since craniofacial deformities also result from mesenchymal dysplasias, there may be a causal relationship between them and mitral valve prolapse. Mitral valve prolapse is reviewed briefly in relation to the embryologic development of the facial skeleton. A slightly increased incidence of mitral valve prolapse has been noted but not statistically studied by the authors in their orthognathic patient population. It is hypothesized that patients with mitral valve prolapse have a typical facies that can be cephalometrically measured and identified.

Mitral valve prolapse: definition and implications in athletes

Mitral valve prolapse is probably the most common cardiac valve disorder, affecting approximately 5% of the population. Although it is genetically determined, its clinical manifestations do not usually become evident before adulthood. In the setting of a cardiology referral center, a mitral valve prolapse syndrome, consisting of nonspecific symptoms, repolarization changes on the electrocardiogram and arrhythmias, has been identified. However, doubt has recently been expressed about the existence of such a syndrome. The prognosis of mitral valve prolapse is generally favorable but infrequent complications do occur and include transient ischemic attacks, progression of mitral regurgitation with or without ruptured chordae tendineae, infective endocarditis and sudden death. The symptoms and the complications are not usually related to physical activity. A permissive attitude toward participation of patients with mitral valve prolapse in competitive athletics is probably warranted; however, it would appear reasonable to disqualify athletes with mitral valve prolapse in the following circumstances: history of syncope; disabling chest pain; complex ventricular arrhythmias, particularly if induced or worsened by exercise; significant mitral regurgitation; prolonged QT interval; Marfan's syndrome; and family history of sudden death.

Vertical left ventricular angulation assessed by thallium 201 myocardial perfusion imaging in patients with mitral valve prolapse

Mitral valve prolapse has been associated with septal to aortic root angle abnormalities determined by echocardiography. Thallium 201 imaging in the anterior view permits visualization of the left ventricular long axis. In the present study, the vertical angle was defined as the angle formed by the long axis of the left ventricle and a horizontal line. The vertical angle was determined in 25 patients who had 201 TL stress testing and M-mode echocardiography. Group I (11 patients) had mitral valve prolapse and group II (14 patients) did not have mitral valve prolapse. The vertical angle and ultrasound were read blinded to each other. Height, weight, and body surface area were compared for the two groups, and receiver operator curve analysis performed. Vertical angle measured by TL 201 was significantly more vertical in patients with mitral valve prolapse. Receiver operator curve analysis showed that an angle of greater than 30 degrees successfully identified 9/11 patients with mitral valve prolapse, with a sensitivity of 82% and a specificity of 79%. There were no significant differences in height, weight, or body surface area between the two groups. Thus, patients with mitral valve prolapse have more vertically positioned hearts than patients without mitral valve prolapse, independent of body habitus. The different appearance of a vertically oriented heart may contribute to false-positive readings of TL 201 images.

Cardiac involvement in congenital myopathy

We examined cardiac changes in 8 patients (4 men and 4 women, age 21-43 years) with congenital myopathy proven by skeletal muscle biopsy. Of 8 patients, 4 showed cardiac changes, including 1 with cytoplasmic body myopathy (patient 1), 2 with minimal change myopathy (patients 2 and 3) and 1 with nemaline myopathy (patient 4). Patients 1 and 2 showed left ventricular dilatation with severe global hypokinesis of left ventricular wall. These clinical features were quite similar to those of dilated cardiomyopathy and the patients were in NYHA class 3 or 4. Patient 3 had severe mitral regurgitation with mitral valve prolapse. This patient also had a persistent left superior vena cava and hypoplasia of the aorta, and her cardiac function was in NYHA class 3. Patient 4 showed moderate global left ventricular hypokinesis but the left ventricle was not dilated. This patient also had sino-atrial block and type A Wolff-Parkinson-White syndrome. His cardiac function was NYHA class 1. In conclusion, various types of congenital myopathy are associated with cardiac changes which can result in severe congestive heart failure.

Mitral valve prolapse in myotonic dystrophy

Forty-three patients with myotonic dystrophy (MyD) and 43 age- and sex-matched controls were prospectively evaluated for mitral valve prolapse (MVP) using both cardiac auscultation and echocardiography (ECHO). Prevalence of MVP was significantly increased in MyD patients when using either abnormal auscultation plus abnormal ECHO (23.3%, P less than 0.02) or abnormal ECHO alone (30%, P less than 0.01) as diagnostic criteria for MVP. Frequency of MVP was even more increased in patients with a thin, flat chest compared with patients with normal physical appearance (P less than 0.007). These findings are in support of the concept that the increased frequency of MVP in neuromuscular disorders is likely due to geometrical changes of the heart caused by thorax deformities, rather than structural changes of the mitral valve. For this reason, MVP in MyD probably belongs to the entity of so-called benign, secondary MVP. This is further supported by the absence of symptoms of "systemic" complications of MVP in our patient population.

Bodily habitus and mitral valve prolapse

We investigated the hypothesis that patients with idiopathic mitral valve prolapse (MVP) have distinctive anthropometric characteristics as part of an ill-defined connective tissue abnormality. In 100 consecutive patients with MVP identified at echocardiography, 56 women and 44 men (age range 28-78 years), we compared measurements of height, weight, arm span, upper and lower body segments, anteroposterior chest diameter, anteroposterior chest diameter/height index, body mass index, and metacarpal index with those from an age and sex matched control group. We also compared the frequency of thoracic asymmetry in MVP patients and controls. Both male and female MVP patients had lower body mass indices than their controls (p less than 0.01 and p less than 0.01 and p less than 0.001, respectively). Women with MVP were lighter than their controls (p less than 0.001) and the same trend was seen in men (p = 0.14). There were no significant differences with any of the other measurements or in the frequency of thoracic asymmetry. We conclude that patients of both sexes with idiopathic MVP are leaner than control subjects but do not otherwise have a specific bodily habitus or an increased frequency of thoracic cage abnormalities. The findings do not support the hypothesis of an underlying generalised connective tissue abnormality but raise the interesting question of why MVP patients should be lean.

The "straight back" syndrome: current perspective more often associated with valvular heart disease than pseudoheart disease: a prospective clinical, electrocardiographic, roentgenographic, and echocardiographic study of 50 patients

Fifty consecutive patients (36 male, 14 female, mean age 28 years) who had heart murmurs and clinical and radiographic evidence of straight upper dorsal spine (straight back syndrome, SBS) underwent detailed clinical, electrocardiographic, roentgenographic, and echocardiographic evaluation. Palpable systolic thrill noted in one (2%) and widened S2 with persistent splitting in 2 (4%) patients were uncommon. Murmurs were invariably systolic in nature. Those located at the base of the heart in 19 (38%) patients were ejection in type and best heard during expiration. Those located at the apex in 26 (52%) patients were either mid-, late-, or pansystolic, and often associated with midsystolic click. Five (10%) patients had both types of murmurs. Diastolic murmurs were not heard in any patient. EKGs were normal in the majority. Cardiomegaly (C:T greater than 55%) was present in only 5 (10%) and dilatation of the main pulmonary artery in 2 (4%) patients. Thus the incidence of pseudoheart disease (PsHD) was small (14%). Echocardiograms were normal in 18 (36%) and abnormal in 32 (64%) patients. There was evidence of mitral valve prolapse (MVP) in 29 (58%) patients and 3 (6%) had evidence of bicuspid aortic valve (BAV). In a control group of 40 age- and sex-matched patients (26 male, 14 female, mean age 29.5 years), who also had heart murmurs but lacked straight upper dorsal spine, only 7 (17.5%) had MVP and none had BAV. The difference is both clinically and statistically significant (p less than 0.001). It is concluded that SBS is more often associated with valvular heart disease (MVP and BAV) than PsHD. Therefore, the diagnosis of SBS should remain presumptive until echocardiography has been performed to exclude MVP and BAV. SBS patients who have valvular heart disease should receive infective endocarditis prophylaxis.

Mitral valve prolapse related to geometrical changes of the heart in cases of progressive muscular dystrophy

The significance of geometrical changes of the heart for the development of mitral valve prolapse (MVP) was studied by echocardiograms and chest x-ray films in 58 cases of progressive muscular dystrophy (PMD). The incidence of MVP was significantly higher (p less than 0.001) in cases where the thoracic spine was straight or lordotic compared with cases of kyphotic thoracic spine. The flattening of the thorax associated with deformation of the thoracic spine was correlated with the left atrial dimension and left ventricular dimension (r = 0.62, r = 0.37, respectively; p less than 0.001), and MVP developed predominantly in cases with flattened thorax and small left atrial or left ventricular dimensions. The left atrial and left ventricular dimensions were significantly smaller in cases with MVP compared to cases without MVP (p less than 0.001, p less than 0.005, respectively). When both the left atrial and the left ventricular dimension shortened to certain levels, MVP was observed in almost all cases. From these results, it was suggested that the portion from the left atrium to the left ventricle was pressed by the forward bending of the thoracic spine, and the subsequent geometrical changes of the mitral ring and the left ventricle could produce redundancy of the chorda tendinea of the mitral valve, resulting in the occurrence of MVP.

Familial occurrence of mitral valve prolapse: is this related to the straight back syndrome?

Familial prevalence of mitral valve prolapse in a Chinese population was determined in 22 propositi of whom 10 had straight back (group A), three had abnormally high metacarpal index (group B), and nine had neither (group C). Of 71 (32 male and 39 female subjects) first degree relatives screened, mitral valve prolapse was found in 19 (seven male and 12 female subjects) (26.8%). The familial prevalence among groups A, B, and C was 20%, 30%, and 38.5%, respectively. Our study indicates that the familial occurrence of mitral valve prolapse does not depend on its association with the straight back syndrome.

Mitral valve dysfunction in the Marfan syndrome. Clinical and echocardiographic study of prevalence and natural history

Although mitral regurgitation and fibromyxomatous thickening of the mitral leaflets have long been recognized as such, mitral valve prolapse has only recently been added as one of the pleiotropic features of the Marfan syndrome. The prevalence, age of onset, and natural history of mitral valve dysfunction in this condition are uncertain. Therefore, all patients in one clinic who met strict diagnostic criteria for the Marfan syndrome and who had clinical and echocardiographic examinations before age 22 years were reviewed. Of the 166 patients (84 males, aged 11.9 +/- 0.6 years [mean +/- SEM]; and 82 females, 11.0 +/- 0.6 years), 52 percent had auscultatory and 68 percent had echocardiographic evidence of mitral valve dysfunction, generally mitral valve prolapse. Prevalence did not differ between the sexes. Follow-up in 115 patients averaged five examinations over a mean of four years; 17 percent were followed for more than six years. Criteria for progression of mitral valve dysfunction were: (1) on auscultation, the appearance of new systolic clicks or apical systolic murmurs, a mitral regurgitant murmur increased by two grades, or appearance of congestive heart failure not due to aortic regurgitation; and (2) on echocardiography, the new appearance of mitral valve prolapse or abnormally increased left atrial dimension. Nearly half the patients met at least one criterion and one quarter had both auscultatory and echocardiographic evidence of progressive mitral valve dysfunction. Twice as many females demonstrated worse mitral valve function with time. Eight of the 166 patients either died as a result of mitral valve dysfunction or required mitral valve replacement. Severe mitral regurgitation developed in an additional 15 patients. Rupture of chordae tendineae was uncommon. Antibiotic prophylaxis was routine, and no cases of bacterial endocarditis of the mitral valve occurred. These results suggest that mitral valve dysfunction is extremely common in young patients with Marfan syndrome and usually presents as mitral valve prolapse. Serious mitral regurgitation develops in one of every eight patients by the third decade. Thus, the prevalence and natural history of mitral valve prolapse in the Marfan syndrome appear distinct from mitral valve prolapse associated with other conditions, including idiopathic or familial mitral valve prolapse.

Skeletal abnormalities in mitral-valve prolapse

One hundred and fifteen Chinese patients with mitral-valve prolapse were evaluated for skeletal abnormalities, to determine their prevalence and interrelation. Measurements of thoracic dimensions from radiographs differed significantly from the normal population. The commonest thoracic abnormality was the straight back, being present in 37.5% of the male and 26.9% of the female patients. Accurate quantitation of thoracic kyphosis was difficult. Either the ratio between antero-posterior and transverse thoracic diameters or a vertebral index characterised the straight back. Other abnormalities included scoliosis, sternal and rib deformities. The mean of metacarpal indices for the patients was also significantly higher than the normal mean. An abnormal metacarpal index was present in 20.9%. There was dissociation between peripheral and thoracic skeletal abnormalities. The diagnostic, aetiological and prognostic implications of associated skeletal abnormalities were discussed.

Association of mitral-valve prolapse with low body-weight and low blood pressure

Subjects with mitral-valve prolapse (MVP) have been observed to have an asthenic body build. To determine whether body-weight differed between individuals with inherited MVP and normal subjects, 177 relatives of 45 patients with MVP were studied, 35 female and 19 male relatives had MVP, and 51 female and 72 male relatives did not. There was no difference in mean height between relatives with and without MVP, but those with MVP weighed significantly less. Blood pressure was also significantly lower in relatives with MVP than in normal relatives. It is suggested that the lower blood pressure and the possible beneficial effects of lower weight on other cardiovascular risk factors may provide a selective advantage to carriers of the MVP gene, explaining its high prevalence in the general population. These findings may provide the first example of a common inherited condition which is systematically associated with changes in body-weight and blood pressure.

Primary versus secondary mitral valve prolapse: clinical features and implications

This study considers the implications that two types of mitral valve prolapse exist. One is primary, and consists of a basic abnormality of the mitral apparatus. While the etiology of this lesion may not always be the same, the major gross abnormalities are usually constant. Secondary mitral valve prolapse generally exists merely as a consequence of reduced or abnormal ventricular dimensions, and usually appears to be a benign phenomenon.

Somatotype and idiopathic mitral valve prolapse

Records from 18 subjects with angiographic idiopathic mitral valve prolapse, 28 subjects with merely exaggerated posterior mitral leaflet systolic bulging, and 100 subjects with normal hemodynamic and angiographic findings were compared with regard to age, sex, height, weight, ponderal index (height/3 square root weight), auscultatory and echocardiographic abnormalities. Chest x-ray films available for subjects with mitral valve prolapse were reviewed. The ponderal index of subjects with mitral valve prolapse (13.1 +/- 0.8) differed from that of subjects with merely exaggerated posterior mitral leaflet systolic bulging (12.6 +/- 0.7) (P less than 0.02) and from that of subjects without angiographic abnormality (12.3 +/- 0.8) (P less than 0.001). The three groups differed in ponderal index when equated statistically for age, height, weight, and sex (P less than 0.001). Among mitral valve prolapse patients, an asthenic habitus occurred independent of the presence of thoracic skeletal abnormalities.

Retinal emboli in patients with mitral valve prolapse

Small fibrin-platelet emboli caused by prolapsed mitral valves may cause retinal occlusive disease with a wide range of ophthalmic manifestations, including amaurosis fugax in young people, retinal or choroidal arteriolar occlusion, and retinal neovascularization (atypical Eales' disease). Six patients with retinal occusive disease underwent extensive noninvasive cardiac and systemic tests and were found to have prolapsed mitral valves. Patients with unexplained ocular emboli should be examined by a cardiologist for possible mitral valve prolapse.

Mitral valve prolapse: etiology, diagnosis, and management

Mitral valve prolapse is a common cardiac anomaly in which diagnosis is generally made by auscultation. In a typical case, a midsystolic click followed by a late systolic murmur is heard, although this pattern can vary. Selected pharmacologic agents (vasopressors and vasodilators) may be useful in diagnosis, and echocardiography can be helpful in cases without auscultatory signs. In the majority of cases, mitral valve prolapse is benign and no specific treatment is needed except reassurance and perhaps endocarditis prophylaxis. Patients with chest pain and symptomatic arrhythmias may benefit from propranolol, those with ventricular tachycardia should receive antiarrhythmic therapy, and those with abnormal resting ECGs or frequent ventricular premature beats should be further tested because of increased risk of sudden death or possibility of associated ischemic heart disease.

Ventricular fibrillation in a patient with unsuspected mitral valve prolapse and a prolonged Q-T interval

Mitral valve prolapse is a common cardiac abnormality associated with arrhythmias and sudden death. In most instances it can be diagnosed on the basis of physical findings. Those patients who are symptomatic or who display electrocardiographic abnormalities appear to be most susceptible to arrhythmias and, therefore, may be at increased risk for anaesthesia. Because the syndrome is relatively common and may present a very innocent clinical picture, anaesthetists should be aware of this condition and the problems it may present. A case of mitral valve prolapse syndrome associated with ventricular fibrillation on induction of anaesthesia is reported. The symptoms and pathophysiology of the disorder are reviewed and the potential problems and the anaesthetic management are discussed.

The HLA antigens and ABO blood groups in an American Black population with mitral valve prolapse

A total of 42 American Black patients with mitral valve prolapse and 194 healthy individuals of similar ethnic background were tested for the distribution of various HLA antigens and ABO blood groups. The most significant result was an increased frequency of Bw35 in patients (74%) as compared with controls (39%), with a P value of less than 0.0001; the relative risk was 4.45.

Pulmonary function studies in patients with prolapse of the mitral valve

We studied the pulmonary function and chest x-ray films of 20 nonsmokers with idiopathic prolapse of the mitral valve. Forty-five percent of these patients complained of dyspnea. Of the 16 chest films reviewed, 44 percent had radiographic evidence of pectus excavatum and 25 percent thoracic scoliosis. The most common pulmonary function abnormalities were increased residual volume (63 percent) and a reduced steady state diffusing capacity (50 percent of patients). There was no relationship between the presence of dyspnea and either chest wall deformity of abnormality of pulmonary function. These pulmonary function abnormalities may reflect a pulmonary parenchymal disorder possibly secondary to a connective tissue abnormality in the lung.