The prevalence of mitral valve prolapse in patients undergoing echocardiography for clinical reason

Increased incidence of mitral valve prolapse in children with pectus chest wall deformity

BACKGROUND

Pectus anomalies constitute 95% of chest anomalies. Pectus carinatum (PC) and excavatum (PE) are often asymptomatic in childhood. However, symptoms and signs such as chest pain, dyspnea, and mitral valve prolapse (MVP) can be seen in pectus anomalies. Demographic characteristics and accompanying cardiac signs in children with pectus deformity were investigated.

METHODS

In this study, the clinical findings for children with pectus deformity, and the incidence of MVP and other concomitant heart diseases detected in echocardiographic examinations were evaluated.

RESULTS

Eighty-two children with PE, 27 with PC, and 107 healthy children were included in this study. In the echocardiographic examination of PE, PC patients, and healthy children, MVP was detected with frequencies of 25%, 33%, and 2% respectively.

CONCLUSIONS

The study showed that pectus anomalies were associated with an increased incidence of MVP. All patients with pectus deformity should therefore undergo a screening echocardiogram in adolescence to assess for the presence of MVP.

Echocardiographic assessment of mitral regurgitation

Mitral regurgitation (MR) is one of the most frequent indications for valve surgery in developed countries, and echocardiographic assessment is an essential tool to evaluate its etiologies, severity, and therapeutic indications. The mitral valve apparatus is a complex structure composed of several parts: apart from the mitral valve leaflets and annulus, it also includes the chordae tendineae, papillary muscles, and left ventricular (LV) wall. MR can be caused not only by organic changes of the mitral valve leaflets or chordae (primary MR) but also by extreme mitral annular enlargement or mitral leaflet tethering due to displacement and malfunction of papillary muscles and LV wall (secondary MR). In secondary MR with LV dysfunction, a milder degree of MR can be associated with adverse outcomes compared with primary MR. Grading the severity is the first step in evaluation of indication for surgical/transcatheter interventions. As such, there are several techniques to assess the severity of MR using echocardiography. However, none of the techniques is reliable enough by itself, and it is always recommended to integrate multiple methods. In cases where echocardiographic assessment of MR severity is inconclusive, magnetic resonance may be helpful. In addition to the severity, anatomical information, such as localization in primary MR due to mitral valve prolapse and LV size in secondary MR due to LV dilatation/dysfunction, is an important concern in presurgical echocardiography. Transesophageal echocardiography and three-dimensional echocardiography are key techniques for anatomical evaluation including mitral valve and LV volumes. In transcatheter intervention for MR, echocardiography plays a pivotal role as a guide for procedures and endpoints. In this review article, the authors provide a comprehensive summary of current standards of echocardiographic assessment of MR.

Utilization of echocardiography in Ehlers-Danlos syndrome

OBJECTIVES

This study assessed the frequency and utility of echocardiographic examination in patients with all forms of Ehlers-Danlos syndrome and sought to identify clinical variables associated with an abnormal echocardiogram.

DESIGN/SETTING

This was a retrospective study of all patients carrying a diagnosis of Ehlers-Danlos syndrome of any type who were evaluated by a pediatrician or pediatric subspecialist at a single tertiary medical center with an affiliated children's hospital during the period January 2013 to December 2018.

PATIENTS

Chart review was performed on all patients carrying a diagnosis of Ehlers-Danlos syndrome in the electronic medical record.

OUTCOME MEASURES

Data from genetics examination, cardiovascular examination where applicable, genetic test results when available, and echocardiography were recorded.

RESULTS

Of 262 patients identified, echocardiography and cardiac evaluation were common occurring in 90% and 50% of patients with any form of Ehlers-Danlos syndrome. Cardiovascular complications occurred in 50% of patients with vascular Ehlers-Danlos syndrome but echocardiography was normal in all. Aortic dilation was common in classic Ehlers-Danlos syndrome but absent in hypermobile Ehlers-Danlos syndrome. Mitral valve prolapse and bicuspid aortic valve occurred at the same incidence as the general population. Cardiac symptoms were present in 12% but did not correlate with abnormal cardiac structure. Presentation with symptoms of musculoskeletal pain was inversely related to the presence of cardiac pathology.

CONCLUSIONS

In light of the absence of cardiac pathology in patients with hypermobile Ehlers-Danlos syndrome, routine cardiac evaluation and echocardiography are not required for patients with hypermobile Ehlers-Danlos syndrome.

Trends in mitral valve prolapse: a tertiary care center experience in Jeddah, Saudi Arabia

Background

Mitral valve prolapse (MVP) is the most common cardiac valvular abnormality in developed countries and it is associated with considerable morbidity and mortality.

Aim of work

To study the clinical presentations, risk factors, and echocardiographic features of patients with MVP in Jeddah, Saudi Arabia.

Materials and methods

A retrospective chart review study was conducted in King Abdulaziz teaching hospital in Jeddah, Saudi Arabia, from 2007 to 2017. All patients with MVP who were admitted at the hospital during this time period were recruited to this study, and demographic, clinical, and echocardiographic variables were analyzed using IBM SPSS.

Results

Ninety-seven patients were recruited to this study, with a mean age of 43.82±16.16 years. Females constituted 67%. The body mass index (BMI) was 24.9±6.3 kg/m². Hypertension, diabetes, and dyslipidemia occurred in 19.6%, 5.2%, and 5.2% of patients, respectively. A single patient had Marfan syndrome. Chest pain, palpitations, and dyspnea were the presenting symptoms in 23.7%, 11.3%, and 9.3% of patients, respectively, with elderly individuals presenting disproportionally (93.3%) with palpitations. Fifty-five percent of patients had an anterior leaflet prolapse. The presence of posterior leaflet prolapse and severe mitral regurgitation (MR) was significantly associated with left atrial and left ventricular dilatation (P<0.05 and P<0.001, respectively).

Conclusion

MVP is more prevalent in women and middle-aged individuals with normal BMIs in this population. The most common clinical presentations were chest pain, palpitations, and dyspnea, which did not differ significantly with age or gender. The anterior leaflet was the most commonly prolapsed in the studied patients and presented with mild MR. Posterior leaflet MVP, while of low prevalence, was associated with severe MR and poor left ventricular function.

Mitral valve prolapse and aortic root dilation in adults with hypermobile Ehlers-Danlos syndrome and related disorders

Ehlers-Danlos syndromes (EDSs) are a group of inherited connective tissue disorders, and among them, classical EDS (cEDS) and hypermobile EDS (hEDS) are the most common. Mitral valve prolapse (MVP) and aortic root dilation (ARD) have previously been reported to occur at an increased frequency within cEDS and hEDS. More recently, a study performed in the pediatric population did not show increased prevalence (Ritter et al., American Journal of Medical Genetics Part A, 173(6), 1467-1472, 2017). The purpose of this study was to review a large population of individuals with cEDS, hEDS, and hypermobility spectrum disorders to determine the frequency of MVP and ARD. A retrospective chart review of 209 individuals with echocardiograms was performed. Overall, 6.4% (13/209) had MVP and 1.6% (3/189) were found to have ARD. Although the presence of MVP is higher than what has been reported in the general population, no patients had severe MVP or required surgical intervention. No patients in this cohort had an aortic root diameter requiring surgical repair. Based on the results of this study and previous studies, routine echocardiograms to assess for valvular diseases and ARD may not be necessary unless warranted by presence of symptoms or family history.

Sudden cardiac arrest and coexisting mitral valve prolapse: a case report and literature review

The aetiology of sudden cardiac arrest can often be identified to underlying cardiac pathology. Mitral valve prolapse is a relatively common valvular pathology with symptoms manifesting with increasing severity of mitral regurgitation (MR). It is unusual for severe MR to be present without symptoms, and there is growing evidence that this subset of patients may be at increased risk of sudden cardiac arrest or death. The difficulty lies in identifying those patients at risk and applying measures that are appropriate to halting progression to cardiac arrest. This article examines the association of mitral valve prolapse with cardiac arrests, the underlying pathophysiological process and the strategies for identifying those at risk.

Pre-participation screening for the prevention of sudden cardiac death in athletes

Pre-partecipation screening is the systematic practice of medically evaluating large populations of athletes before participation in sport activities for the purpose of identifying abnormalities that could cause disease progression or sudden death. In order to prevent sudden cardiac death (SCD), cardiovascular screening should include a strategy for excluding high-risk subjects from athletic and vigorous exercise. There are two major screening programmes in the world. In the United States competitive athletes are screened by means of family and personal history and physical examination. In Italy there is a mandatory screening for competitive athletes, which includes a resting electrocardiogram (ECG) for the detection of cardiac abnormalities. The most important issue to be addressed is whether a screened subject is really guaranteed that she/he is not suffering from any cardiac disease or at risk for SCD. Conceivably, the introduction of echocardiogram during the pre-participation screening, could be reasonable, despite the discrete sensitivity of ECG, in raising clinical suspicions of severe cardiac alterations predisposing to SCD. It is clear that the cost-benefit ratio per saved lives of the ECG screening is a benchmark of the Public Health policy. On the contrary, the additional introduction of echocardiography in a large population screening programme seems to be too much expansive for the Public Health and for this reason not easily practicable, even if useful and not invasive. Even if we strongly believe that a saved life is more important than any cost-efficacy evaluation, the issue of the economical impact of this approach should be further assessed.

Medical complications, clinical findings, and educational outcomes in adults with Noonan syndrome

Noonan syndrome (NS) is a heterogeneous developmental disorder caused by missense mutations in genes involved in the Ras/MAPK signaling pathway, a major mediator of early and late developmental processes. The diagnosis of NS is made on clinical grounds with molecular confirmation of a mutation found in 63% of cases. Key clinical features include short stature, cardiac defects, developmental delay, lymphatic dysplasias, bleeding tendency, and a constellation of distinctive facial features and physical exam findings. The prevalence of medical issues or the development of new ones in adults with NS is not well-studied. This cross-sectional study reports on the prevalence of clinical conditions and their ages of onset in a cohort of 35 adolescents and adults with NS aged 16-68 years old (mean age 28 years). In this cohort, 34 of 35 subjects (97%) had had full PTPN11 sequencing; 37% were PTPN11 positive, 23% were SOS1 positive, and 3% were BRAF positive. Mean adult height in both men and women was at the 3rd-10th centile. The most prevalent clinical findings in this cohort included pulmonary valve stenosis (71%), easy bruising (63%), GERD (60%), constipation (51%), scoliosis (54%), chronic joint pain (54%), lymphedema (49%), depression (49%), anxiety (49%), Chiari malformation (20%), and osteopenia/osteoporosis (14%). In summary, adults with NS are affected by multi-organ morbidity and require special medical management aimed towards the most prevalent and serious known medical complications. Larger studies characterizing the clinical conditions found in NS adults are needed to provide potential genotype-phenotype correlations that may aid in clinical management.

Juvenile polyposis syndrome: a study of genotype, phenotype, and long-term outcome

BACKGROUND

Juvenile polyposis syndrome is phentoypically and genotypically heterogeneous. It is associated with an increased risk of GI cancers, and surveillance is recommended. Few data exist that detail the outcomes of surveillance in juvenile polyposis syndrome.

OBJECTIVE

The aim of this study was to review clinical features, genetic mutations, and long-term outcome data in patients with juvenile polyposis syndrome.

DESIGN

This study is a retrospective review.

SETTING

The Polyposis Registry, St Mark's Hospital, was used in the performance of this study.

PATIENTS

Patients with juvenile polyposis syndrome who were followed up at our institution were included.

RESULTS

Forty-four patients (27 male) from 30 kindreds were included. Fifteen were diagnosed by screening, and 29 presented symptomatically. Nineteen patients had SMAD4 mutation and 9 had BMPR1A mutation. Five patients (11%) had valvular heart disease. Telangiectasia/vascular abnormalities were observed in 4 (9%) patients, and macrocephaly was observed in 5 (11%). Six patients (14%) developed cancer; 4 had cancer at the time of diagnosis of juvenile polyposis syndrome, 3 developed cancer while on surveillance (1 patient had a second primary). All patients with advanced upper GI disease had SMAD4 mutations. Where germline mutation was known, all patients with telangiectasia had SMAD4 mutation. Seven patients required GI surgery at our institution: colectomy and ileorectal anastomosis (1), restorative proctocolecotomy (1), anteroposterior excision for rectal cancer (1), gastrectomy (2), and laparotomy and intraoperative enteroscopy (1). There were no complications of endoscopic surveillance. Colonic polyps predominated; 535 of 767 (69.8%) of colonic polyps were right sided. One patient had a solitary significant small-bowel polyp. Sixty-five juvenile polyps contained dysplasia (mild to moderate). Two patients had severe dysplasia or cancer found in carpeting polyps.

LIMITATIONS

This is a retrospective review. The cohort size, although modest, is good for such a rare condition.

CONCLUSION

Extraintestinal features are common. Gastrointestinal surveillance is safe. Most colonic polyps are right sided, and detecting dysplasia is uncommon. Carpeting polyps are of particular concern.

Prevalence of mitral valve prolapse in residents living at moderately high altitude

OBJECTIVE

Prolapse of mitral valve leaflets is a frequent disorder and the most common cause of severe mitral regurgitation in western countries. However, little is known about the effects of altitude on mitral valve prolapse. We studied the prevalence and echocardiographic characteristics of mitral valve prolapse at moderately high altitude and sea level.

METHODS

A total of 936 consecutive subjects who were admitted to 2 study institutions at Kars, Turkey (1750 m) and Istanbul, Turkey (7 m) were enrolled in this study to determine prevalence of mitral valve prolapse. Demographic and 2-dimensional echocardiographic characteristics of participants were recorded.

RESULTS

Prevalence of mitral valve prolapse was found to be significantly higher in people living at moderate altitude compared with those living at sea level (6.2% vs 2.0%; P = .007). Overall echocardiographic features regarding valve thickness (4.1 ± 0.80 mm vs 3.6 ± 0.66 mm; P = 0.169), maximal valve prolapse (4.6 ± 2.08 mm vs 3.9 ± 0.91 mm; P = .093), and frequency of mitral regurgitation (89% vs 73%; P = .65) were similar between groups, although anterior valve prolapse was seen more frequently at moderate altitude (50% vs 11%; P = .056) and posterior leaflet prolapse was significantly more frequent at sea level (66% vs 10%; P = .002).

CONCLUSIONS

Mitral valve prolapse is more frequently observed at moderately high altitudes. Further studies are needed to determine clinical importance of our findings.

Autonomic dysregulation as a novel underlying cause of mitral valve prolapse: a hypothesis

Mitral valve prolapse is a common valvular abnormality that is caused by myxomatous degeneration, characterized macroscopically by leaflet thickening and redundancy accompanied with histologically marked proliferation of the spongiosa and mucopolysaccharide acid replacement of leaflet collagen in the prolapse leaflets. Nevertheless, the discrepant natural history and various concomitant syndromes cannot be explained completely by the current genetic autosomal dominant inheritance theory. In addition, autonomic dysregulation has been commonly reported in mitral valve prolapse, but has never been indicated as a major underlying cause. This article attempts to interpret the occurrence of primary pathology and progression in mitral valve prolapse on a common basis of improper autonomic tone. The imbalanced background of autonomic nervous firing leads to disharmonized synthetic/catabolism balance in the extracellular matrix, disrupted transition in the interstitial cellular component and invalided anti-inflammatory pathway in the endothelium, which trigger and accelerate the progression of this condition. Such a hypothesis not only unifies the seemingly disparate syndromes and valvular disorder, but also has implications for future biopharmaceutical and mechanical treatment.

Cross-sectional and longitudinal assessment of aortic root dilation and valvular anomalies in hypermobile and classic Ehlers-Danlos syndrome

OBJECTIVES

To delineate the prevalence of cardiac findings in hypermobile and classic Ehlers-Danlos syndrome and provide longitudinal analysis of aortic root growth.

STUDY DESIGN

A retrospective chart review was conducted, and data were analyzed for cross-sectional prevalence of aortic dilation and valvular anomalies. The clinical implications of aortic root growth were determined by assessment of progression of aortic root measurements over time and clinical symptoms.

RESULTS

Patients whose first echocardiogram was obtained in late childhood or adulthood were less likely to have aortic dilation (P < .002) than those whose first echocardiogram was obtained in early childhood. Longitudinally, seven individuals had dilated aortas before age 14, and only one individual continued to show dilation after age 14 (P = .0143). No patient with a normal aortic root in childhood had development of dilation in adulthood. Fifteen of the 252 patients (6.0%) had mitral valve prolapse (MVP), although only one patient (0.4%) had MVP that was mild to moderate.

CONCLUSIONS

Although aortic root size and MVP are increased in patients with these types of Ehlers-Danlos syndrome, they tend to be of little clinical consequence. Echocardiography may still be warranted as part of cardiovascular assessment, but decreased frequency of screening is recommended especially in symptom-free adults.

Prevalence of mitral valvar prolapse in young athletes

BACKGROUND

The prevalence of mitral valvar prolapse has been reported to be between 0.6 and 21%. The goal of our study was to evaluate its prevalence in young athletes who underwent hand-held echocardiography as a screening mostly in southern California.

METHODS

We retrospectively analyzed 1742 echocardiograms that were performed as a part of a cardiac screening of teenage athletes. The total prevalence of mitral valvar prolapse was calculated and stratified based on gender.

RESULTS

We screened a total of 1172 male and 570 female high school athletes. The echocardiographic prevalence of mitral valvar prolapse was 0.9%. The prevalence was similar in both genders, at 1.2% in male and 0.7% in female athletes.

CONCLUSION

The prevalence of mitral valvar prolapse in young athletes mostly in southern California was found to be less than 1%, and was similar in both genders.