Anthropometric and physiologic correlates of mitral valve prolapse in a biethnic cohort of young adults: the CARDIA study

Arrhythmogenic Mitral Valve Prolapse: Can We Risk Stratify and Prevent Sudden Cardiac Death?

Ventricular arrhythmias associated with mitral valve prolapse (MVP) and the capacity to cause sudden cardiac death (SCD), referred to as 'malignant MVP', are an increasingly recognised, albeit rare, phenomenon. SCD can occur without significant mitral regurgitation, implying an interaction between mechanical derangements affecting the mitral valve apparatus and left ventricle. Risk stratification of these arrhythmias is an important clinical and public health issue to provide precise and targeted management. Evaluation requires patient and family history, physical examination and electrophysiological and imaging-based modalities. We provide a review of arrhythmogenic MVP, exploring its epidemiology, demographics, clinical presentation, mechanisms linking MVP to SCD, markers of disease severity, testing modalities and management, and discuss the importance of risk stratification. Even with recently improved understanding, it remains challenging how best to weight the prognostic importance of clinical, imaging and electrophysiological data to determine a clear high-risk arrhythmogenic profile in which an ICD should be used for the primary prevention of SCD.

Degenerative mitral regurgitation due to flail leaflet: sex-related differences in presentation, management, and outcomes

BACKGROUND AND AIMS

Presentation, outcome, and management of females with degenerative mitral regurgitation (DMR) are undefined. We analysed sex-specific baseline clinical and echocardiographic characteristics at referral for DMR due to flail leaflets and subsequent management and outcomes.

METHODS

In the Mitral Regurgitation International Database (MIDA) international registry, females were compared with males regarding presentation at referral, management, and outcome (survival/heart failure), under medical treatment, post-operatively, and encompassing all follow-up.

RESULTS

At referral, females (n = 650) vs. males (n = 1660) were older with more severe symptoms and higher MIDA score. Smaller cavity diameters belied higher cardiac dimension indexed to body surface area. Under conservative management, excess mortality vs. expected was observed in males [standardized mortality ratio (SMR) 1.45 (1.27-1.65), P < .001] but was higher in females [SMR 2.00 (1.67-2.38), P < .001]. Female sex was independently associated with mortality [adjusted hazard ratio (HR) 1.29 (1.04-1.61), P = .02], cardiovascular mortality [adjusted HR 1.58 (1.14-2.18), P = .007], and heart failure [adjusted HR 1.36 (1.02-1.81), P = .04] under medical management. Females vs. males were less offered surgical correction (72% vs. 80%, P < .001); however, surgical outcome, adjusted for more severe presentation in females, was similar (P ≥ .09). Ultimately, overall outcome throughout follow-up was worse in females who displayed persistent excess mortality vs. expected [SMR 1.31 (1.16-1.47), P < .001], whereas males enjoyed normal life expectancy restoration [SMR 0.92 (0.85-0.99), P = .036].

CONCLUSIONS

Females with severe DMR were referred to tertiary centers at a more advanced stage, incurred higher mortality and morbidity under conservative management, and were offered surgery less and later after referral. Ultimately, these sex-related differences yielded persistent excess mortality despite surgery in females with DMR, while males enjoyed restoration of life expectancy, warranting imperative re-evaluation of sex-specific DMR management.

Arrhythmic mitral valve prolapse: a practical approach for asymptomatic patients

Mitral valve prolapse (MVP) is usually regarded as a benign condition though the proportion of patients with a life-threatening arrhythmic MVP form remains undefined. Recently, an experts' consensus statement on arrhythmic MVP has proposed approaches for risk stratification across the spectrum of clinical manifestation. However, sudden cardiac death may be the first presentation, making clinicians focused to early unmasking this subset of asymptomatic patients. Growing evidence on the role of cardiac imaging in the in-deep stratification pathway has emerged in the last decade. Pathology findings have suggested the fibrosis of papillary muscles and inferobasal left ventricular wall as the malignant hallmark. Cardiac magnetic resonance, while of limited availability, allows the identification of this arrhythmogenic substrate. Therefore, speckle-tracking echocardiography may be a gateway to prompt referring patients to further advanced imaging investigation. Our review aims to summarize the phenotypic features linked to the arrhythmic risk and to propose an image-based algorithm intended to help stratifying asymptomatic MVP patients.

Arrhythmic mitral valve prolapse and mitral annular disjunction: pathophysiology, risk stratification, and management

Mitral valve prolapse (MVP) is the most frequent valve condition but remains a conundrum in many aspects, particularly in regard to the existence and frequency of an arrhythmic form (AMVP) and its link to sudden cardiac death. Furthermore, the presence, frequency, and significance of the anatomic functional feature called mitral annular disjunction (MAD) have remained widely disputed. Recent case series and cohorts have shattered the concept that MVP is most generally benign and have emphasized the various phenotypes associated with clinically significant ventricular arrhythmias, including AMVP. The definition, evaluation, follow-up, and management of AMVP represent the focus of the present review, strengthened by recent coherent studies defining an arrhythmic MVP phenotypic that would affect a small subset of patients with MVP at concentrated high risk. The role of MAD in this context is of particular importance, and this review highlights the characteristics of AMVP phenotypes and MAD, their clinical, multimodality imaging, and rhythmic evaluation. These seminal facts lead to proposing a risk stratification clinical pathway with consideration of medical, rhythmologic, and surgical management and have been objects of recent expert consensus statements and of proposals for new research directions.

Mitral valve prolapse and physical performance in Asian military males: The CHIEF Heart study

The impact of mitral valve prolapse (MVP) and mitral regurgitation (MR) on physical performance has not been examined. Of 1,808 physically fit Asian military males, we compared the physical fitness between 62 subjects with MVP (MVP(+)) and 1,311 age- and anthropometrics-matched controls from the 1,746 participants without MVP (MVP(-)). MVP and MR grade were defined based on the American Society of Echocardiography criteria. Aerobic endurance capacity was evaluated by a 3000-m run and muscular endurance capacity was separately evaluated by 2-min sit-ups and 2-min push-ups. Analysis of covariance was used to determine the difference between groups. As compared to the MVP(-), the MVP(+) completed the 3000-m run test faster (839.2 ± 65.3 sec vs. 866.6 ± 86.8 sec, p = 0.019), but did fewer push-ups (41.3 ± 3.92 vs. 48.0 ± 10.1, p = 0.02) and similar sit-ups within 2 min. Of the MVP(+), those with any MR (trivial, mild or moderate) completed the 3000-m run test faster than those without MR (830.6 ± 61.7 sec vs. 877.2 ± 61.7 sec, p = 0.02). Our findings suggest that in physically active Asian military males, the MVP(+) may have greater aerobic endurance capacity but lower muscular endurance capacity than the MVP(-). The presence of MR may play a role for the MVP(+) to have greater aerobic endurance capacity.

Comparison of the Results of Cardiopulmonary Exercise Testing between Healthy Peers and Pediatric Patients with Different Echocardiographic Severity of Mitral Valve Prolapse

Patients with mitral valve prolapse (MVP) have been reported to have exercise intolerance. However, the underlying pathophysiological mechanisms and their physical fitness remain unclear. We aimed to determine the exercise capacity of patients with MVP through the cardiopulmonary exercise test (CPET). We retrospectively collected the data of 45 patients with a diagnosis of MVP. Their CPET and echocardiogram results were compared with 76 healthy individuals as primary outcomes. No significant differences regarding the patient's baseline characteristics and echocardiographic data were found between the two groups, except for the lower body mass index (BMI) of the MVP group. Patients in the MVP group demonstrated a similar peak metabolic equivalent (MET), but a significantly lower peak rate pressure product (PRPP) (p = 0.048). Patients with MVP possessed similar exercise capacity to healthy individuals. The reduced PRPP may indicate compromised coronary perfusion and subtle left ventricular function impairment.

Watchful surgery in asymptomatic mitral valve prolapse

The most common organic etiology of mitral regurgitation is degenerative and consists of mitral valve prolapse (MVP). Volume overload because of mitral regurgitation is the most common complication of MVP. Advocating surgery before the consequences of volume overload become irreparable restores life expectancy, but carries a risk of mortality in patients who are often asymptomatic. On the other hand, the post-surgical outcome of symptomatic patients is dismal and life expectancy is impaired. In the present article, we aim to bridge the gap between these two therapeutic approaches, unifying the concepts of watchful waiting and early surgery in a "watchful surgery approach".

Mitral Valve Prolapse and Sudden Cardiac Death in Athletes at High Risk

Mitral valve prolapse (MVP) is the most frequent valvulopathy in the general population, with usually a favourable prognosis. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) are the most worrying. The estimated risk of SCD in MVP is between 0.2% to 1.9% per year, including MVP patients with and without severe mitral regurgitation (MR). The association between SCD and MVP is expressed by a phenotype called "malignant MVP" characterized by transthoracic echocardiography (TTE) findings such as bileaflet myxomatous prolapse and mitral annulus disjunction (MAD), ECG findings such as repolarization abnormalities, complex ventricular arrhythmias (c-VAs) and LV fibrosis of papillary muscles (PMs) and inferobasal wall visualized by late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Therefore, attention is raised for patients with "arrhythmic MVP" characterized from an ECG point of view by frequent premature ventricular contractions (PVCs) arising from one or both PMs as well as by T-wave inversion in the inferolateral leads. In athletes, SCD is the most frequent medical cause of death and in young subjects (< 35 years) usually is due to electrical mechanism affecting who has a silent cardiovascular disease and are not considered per se a cause of increased mortality. In MVP, SCD was reported to happen during sports activity or immediately after and valve prolapse was the only pathological aspect detected. The aim of the present paper is to explore the association between SCD and MVP in athletes, focusing attention on ECG, TTE in particular, and CMR findings that could help to identify subjects at high risk for complex arrhythmias and eventually SCD. In addition, it is also examined if sports activity might predispose patients with MVP to develop major arrhythmias.

Characterization of ventricular arrhythmias and sudden cardiac death in subjects with mitral valve prolapse and mitral annular disjunction

Sudden cardiac death is reported as the leading cause of mortality in developed nations. Arrhythmic mitral valve disease, encompassing mitral valve prolapse and/or mitral annular disjunction, is thought to be responsible in a sizable portion of these deaths. Despite this evidence, there are no reliable methods or clinically useful risk stratification schemes to determine which group of patients are at higher risk or may benefit from interventions such as catheter ablation or prophylactic implantation of a defibrillator. The reasons for this lack of guidance include our incomplete understanding of the mechanisms of ventricular arrhythmias and the fact that mitral valve prolapse and disjunction are frequently diagnosed, yet carry an overall low risk of sudden cardiac death. This heterogeneity makes the development of a reliable prediction model based on the presence of common risk factors very difficult. In this review, we summarize the relevant literature regarding the epidemiology, diagnosis, pathophysiology, and management of mitral valve prolapse and mitral annular disjunction and elucidate their role in sudden cardiac death.

Transthoracic echocardiography for arrhythmic mitral valve prolapse: Phenotypic characterization as first step

Mitral valve prolapse (MVP) is the most frequent valvulopathy with a prevalence of 1.2%-2.4% in general population and it is characterized by a benign course. Although it can be associated with some complications, ventricular arrhythmias (VA) and sudden cardiac death (SCD) as ultimate expressions, are the most worrying. The estimated risk of SCD in MVP is between 0.2% and 1.9% per year including both MVP patients with left ventricular (LV) dysfunction due to severe MR and MVP patients without significant MR. The latter ones constitute a particular phenotype called "malignant MVP" characterized by bileaflet myxomatous prolapse, ECG repolarization abnormalities and complex VAs (c-VAs) with polymorphic/right bundle branch block morphology (RBBB) and LV fibrosis of the papillary muscles (PMs) and inferobasal wall secondary to mechanical stretching visualized as late gadolinium enhancement (LGE) areas by cardiac magnetic resonance (CMR). In MVP, the first diagnostic approach is transthoracic echocardiography (TTE) that defines the presence of mitral annular disjunction (MAD) which seems to be associated with "arrhythmic MVP" (AMVP). From an ECG point of view, AMVP is characterized by frequent premature ventricular contractions (PVCs) arising from one or both PMs, fascicular tissue, and outflow tract, as well as by T-wave inversion in the inferolateral leads. The aim of the present paper is to describe TTE red flags that could identify MVP patients at high risk to develop complex arrhythmias as supported by the corresponding findings of LGE-CMR and anatomy studies. TTE could be a co-partner in phenotyping high-risk arrhythmic MVP patients.

Diagnosis of Mitral Valve Prolapse: Much More than Simple Prolapse. Multimodality Approach to Risk Stratification and Therapeutic Management

Mitral valve prolapse (MVP) is the most common valvular disease with a prevalence of 2%. It has generally a benign course; however, recent findings suggested an association between MVP and complex arrhythmias and eventually cardiac arrest and for this reason, it is also called arrhythmogenic MVP. Subjects who experience this complication are in general young women, with thickened mitral leaflets or bileaflet prolapse not necessarily associated with severe mitral regurgitation (MR). The nature of the relation between MVP and cardiac arrest is not clearly understood. Actually, the challenging task is to find the cluster of prognostic factors including T-wave inversion, polymorphic premature ventricular contractions, bileaflet prolapse, MR severity, but most importantly, those parameters of hypercontractility, mitral annulus disjunction (MAD), and myocardial fibrosis using a multimodality approach. Transthoracic echocardiography is the first-line imaging modality for the diagnosis of MVP, but also for detecting MAD and hypercontractility, followed by cardiac magnetic resonance for tissue characterization and detection of myocardial and papillary muscle fibrosis, using either late gadolinium enhancement (at the basal segment of the inferolateral wall and papillary muscles) (macro-fibrosis), or diffuse fibrosis by T1 mapping (native and post contrast T1). Moreover, there are also preliminary data on positron emission tomography utilizing 18F-fluorodeoxyglucose as a tool for providing evidence of early myocardial inflammation. The objective of this review article is to provide the clinician with an overview and a practical clinical approach to MVP for risk stratification and treatment guidance.

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.

Arrhythmic Mitral Valve Prolapse: Introducing an Era of Multimodality Imaging-Based Diagnosis and Risk Stratification

Mitral valve prolapse is a common cardiac condition, with an estimated prevalence between 1% and 3%. Most patients have a benign course, but ever since its initial description mitral valve prolapse has been associated to sudden cardiac death. Although the causal relationship between mitral valve prolapse and sudden cardiac death has never been clearly demonstrated, different factors have been implicated in arrhythmogenesis in patients with mitral valve prolapse. In this work, we offer a comprehensive overview of the etiology and the genetic background, epidemiology, pathophysiology, and we focus on the state-of-the-art imaging-based diagnosis of mitral valve prolapse. Going beyond the classical, well-described clinical factors, such as young age, female gender and auscultatory findings, we investigate multimodality imaging features, such as alterations of anatomy and function of the mitral valve and its leaflets, the structural and contractile anomalies of the myocardium, all of which have been associated to sudden cardiac death.

Prevalence and characteristics of mitral valve prolapse in military young adults in Taiwan of the CHIEF Heart Study

The prevalence of mitral valve prolapse (MVP) among middle- and older-aged individuals is estimated to be 2–4% in Western countries. However, few studies have been conducted among Asian individuals and young adults. This study included a sample of 2442 consecutive military adults aged 18–39 years in Hualien, Taiwan. MVP was defined as displacement of the anterior or posterior leaflet of the mitral valve to the mid portion of the annular hinge point > 2 mm in the parasternal long-axis view of echocardiography. Cardiac chamber size and wall thickness were measured based on the latest criteria of the American Society of Echocardiography. The clinical features of participants with MVP and those without MVP were compared using a two-sample t test, and the cardiac structures were compared using analysis of covariance with adjustment for body surface area (BSA). Eighty-two participants were diagnosed with MVP, and the prevalence was 3.36% in the overall population. Compared with those without MVP, participants with MVP had a lower body mass index (kg/m²) (24.89 ± 3.70 vs. 23.91 ± 3.45, p = 0.02) and higher prevalence of somatic symptoms related to exercise (11.0% vs. 4.9%, p = 0.02) and systolic click in auscultation (18.3% vs. 0.6%, p < 0.01). In addition, participants with MVP had greater left ventricular mass (gm) and smaller right ventricular wall thickness (mm) and dimensions (mm) indexed by BSA than those without MVP (149.12 ± 35.76 vs. 155.38 ± 36.26; 4.66 ± 0.63 vs. 4.40 ± 0.68; 26.57 ± 3.99 vs. 25.41 ± 4.35, respectively, all p-values < 0.01). In conclusion, the prevalence and clinical features of MVP in military young adults in Taiwan were in line with those in Western countries. Whether the novel MVP phenotype found in this study has any pathological meaning needs further investigation.

Global Burden of Cardiovascular Diseases and Risk Factors, 1990-2019: Update From the GBD 2019 Study

Cardiovascular diseases (CVDs), principally ischemic heart disease (IHD) and stroke, are the leading cause of global mortality and a major contributor to disability. This paper reviews the magnitude of total CVD burden, including 13 underlying causes of cardiovascular death and 9 related risk factors, using estimates from the Global Burden of Disease (GBD) Study 2019. GBD, an ongoing multinational collaboration to provide comparable and consistent estimates of population health over time, used all available population-level data sources on incidence, prevalence, case fatality, mortality, and health risks to produce estimates for 204 countries and territories from 1990 to 2019. Prevalent cases of total CVD nearly doubled from 271 million (95% uncertainty interval [UI]: 257 to 285 million) in 1990 to 523 million (95% UI: 497 to 550 million) in 2019, and the number of CVD deaths steadily increased from 12.1 million (95% UI:11.4 to 12.6 million) in 1990, reaching 18.6 million (95% UI: 17.1 to 19.7 million) in 2019. The global trends for disability-adjusted life years (DALYs) and years of life lost also increased significantly, and years lived with disability doubled from 17.7 million (95% UI: 12.9 to 22.5 million) to 34.4 million (95% UI:24.9 to 43.6 million) over that period. The total number of DALYs due to IHD has risen steadily since 1990, reaching 182 million (95% UI: 170 to 194 million) DALYs, 9.14 million (95% UI: 8.40 to 9.74 million) deaths in the year 2019, and 197 million (95% UI: 178 to 220 million) prevalent cases of IHD in 2019. The total number of DALYs due to stroke has risen steadily since 1990, reaching 143 million (95% UI: 133 to 153 million) DALYs, 6.55 million (95% UI: 6.00 to 7.02 million) deaths in the year 2019, and 101 million (95% UI: 93.2 to 111 million) prevalent cases of stroke in 2019. Cardiovascular diseases remain the leading cause of disease burden in the world. CVD burden continues its decades-long rise for almost all countries outside high-income countries, and alarmingly, the age-standardized rate of CVD has begun to rise in some locations where it was previously declining in high-income countries. There is an urgent need to focus on implementing existing cost-effective policies and interventions if the world is to meet the targets for Sustainable Development Goal 3 and achieve a 30% reduction in premature mortality due to noncommunicable diseases.

Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis

Background:

Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis.

Methods:

One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5–mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair.

Results:

Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation ( P =0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P =0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P =0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group ( P =0.27).

Conclusions:

In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier NCT02552771.

A single nucleotide deletion resulting in a frameshift in exon 4 of TAB2 is associated with a polyvalular syndrome

OBJECTIVE

Polyvalvularmyxomatous degeneration is a rare clinical condition. A 51-year-old male patient presented at our centre with all four heart valves with myxomatous degeneration and severe mitral and aortic regurgitation due to leaflet prolapse. The patient referred five further family members with valvular heart disease at different stages of presentation. The aim of this study was to investigate the genetic basis of this familial polyvalvularmyxomatous degeneration which was associated with mild dysmorphic facial anomalies and short stature.

DESIGN

A detailed family history was recorded. Nine members of the family, affected or not by valvular heart disease, were studied clinically, echocardiographically and by detailed genetic analyses.

RESULTS

Six of the nine family members had echocardiographic features of different degrees of degenerative heart valve disease. In addition, the affected subjects shared similar mild dysmorphic facial anomalies and short stature. Exome sequencing identified a rare heterozygous single nucleotide deletion in the TAB2 gene in all affected family members, which was absent in the unaffected members.

CONCLUSIONS

A variant in the TAB2 gene is proposed as the cause of syndromic congenital heart disease, displaying congenital myxomatous degenerative heart valve disease, mild dysmorphic fascial anomalies and short stature in this family.

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.

Systematic review and meta-analysis of chordal replacement versus leaflet resection for posterior mitral leaflet prolapse

OBJECTIVES

To compare outcomes of chordal replacement versus leaflet resection techniques for repair of isolated posterior mitral leaflet prolapse.

METHODS

We searched MEDLINE and EMBASE databases for studies that compared chordal replacement ("neo-chord" group) versus leaflet resection ("resection" group) techniques for the treatment of posterior mitral leaflet prolapse. Data were extracted by 2 independent investigators and subjected to a meta-analysis using a random-effects model.

RESULTS

One randomized controlled trial (RCT), 1 propensity-matched study, and 6 unadjusted observational studies, with a total of 1926 patients, met our inclusion criteria. Two studies reported only perioperative outcomes; mean follow-up ranged from 1.0 to 5.9 years in the remaining studies. In pooled data from unadjusted observational studies, annuloplasty ring diameter was higher in the neo-chord group (+1.5 mm; P = .0003), but with high heterogeneity (I² = 91%). Based on limited data, postprocedural left ventricular ejection fraction may be greater in the neo-chord group, but this difference reached statistical significance only in the RCT (+3.4%; P = .03), and not in 2 observational studies that reported this outcome (+2.7%; P = .10). There was no difference in recurrent mitral regurgitation at follow-up between the resection and neo-chord groups; however, patients in the neo-chord group had a lower rate of mitral valve reoperation at follow-up in the unadjusted observational studies (incidence rate ratio, 0.22; P = .0008 [I² = 0%; 4 studies, 1331 patients]).

CONCLUSIONS

Chordal replacement may be associated with greater freedom from reoperation and may lead to improved postoperative left ventricular function compared with leaflet resection. However, these conclusions are supported primarily by data from unadjusted observational studies, and high-quality RCTs of chordal replacement versus leaflet resection are needed.

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial)

BACKGROUND

The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted.

METHODS AND ANALYSIS

This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery.

ETHICS AND DISSEMINATION

Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context.

TRIAL REGISTRATION NUMBER

NCT02552771.

Mitral valve disease--morphology and mechanisms

Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but--even in adult life--remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular-ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease.

Prevalence of mitral valve prolapse and congenital bicuspid aortic valves in black and white patients undergoing cardiac valve operations

The risk factors for aortic and mitral valve diseases that require surgical repair such as congenital bicuspid aortic valve (BAV) and mitral valve prolapse include acquired clinical factors and genetic influences. Whether race affects the prevalence of certain valvular diseases has not been sufficiently investigated. Through the Cleveland Clinic's Cardiovascular Information Registry, we evaluated the data from 40,419 patients who had undergone aortic valve surgery, mitral valve surgery, and/or coronary artery bypass grafting from 1993 to 2007. Of these patients, 38,366 were white and 2,053 were black. The prospective evaluation of valvular disease was coded, identifying the etiology and morphology by echocardiographic, surgical, and pathologic inspection. At baseline, compared to white patients, the black patients were younger, more often women, had a greater body mass index, and a greater prevalence of hypertension, diabetes, tobacco use, and renal disease. The prevalence of congenital BAV and mitral valve prolapse was considerably lower in blacks than in whites (9% vs 25%, p <0.001, and 27% vs 52%, p <0.001, respectively), as was the presence of calcific aortic stenosis (14% vs 28%; p <0.001), pathologically determined aortic valve calcium (50% vs 67%; p <0.001), and mitral valve chordal rupture (13% vs 31%; p <0.001). In conclusion, in the present large surgical series, the valve etiologies and morphology differed among blacks and whites. Despite an adverse cardiovascular risk profile, blacks had a significantly lower prevalence of valvular calcium and degeneration than did the whites and a lower prevalence of congenital BAV and mitral valve prolapse. Our findings offer insight into the influence of race on the development of mitral valve disease and congenital BAV.

Comparison of real-time three-dimensional transesophageal echocardiography to two-dimensional transesophageal echocardiography for quantification of mitral valve prolapse in patients with severe mitral regurgitation

Real-time 3-dimensional (3D) transesophageal echocardiography (TEE) provides more accurate geometric information on the mitral valve (MV) than 2-dimensional (2D) TEE. The aim of this study was to quantify MV prolapse using real-time 3D TEE in patients with severe mitral regurgitation. In 102 patients with severe mitral regurgitation due to MV prolapse and/or flail, 2D TEE quantified MV prolapse, including prolapse gap and width in the commissural view. Three-dimensional TEE also determined prolapse gap and width with the use of the 3D en face view. On the basis of the locations of MV prolapse, all patients were classified into group 1 (pure middle leaflet prolapse, n = 50) or group 2 (involvement of medial and/or lateral prolapse, n = 52). Prolapse gap and prolapse width determined by 3D TEE were significantly greater than those by 2D TEE (all p values <0.001). The differences in prolapse gap and prolapse width between 2D TEE and 3D TEE were significantly greater in group 2 than group 1 (Δ gap 1.3 ± 1.4 vs 2.4 ± 1.8 mm, Δ width 2.5 ± 3.0 vs 4.4 ± 5.1 mm, all p values <0.01). The differences in prolapse gap and width between 2D TEE and 3D TEE were best correlated with 3D TEE-derived prolapse width (r = 0.41 and r = 0.74, respectively). Two-dimensional TEE underestimated the width of MV prolapse and leaflet gap compared to 3D TEE. Two-dimensional TEE could not detect the largest prolapse gap and width, because of the complicated anatomy of the MV. In conclusion, 3D TEE provided more precise quantification of MV prolapse than 2D TEE.

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.

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

BACKGROUND

The prevalence of mitral valve prolapse (MVP) has been reported to be 2.4% according to the Framingham Heart Study. However larger trials have found the prevalence of MVP to be less than 1.5%. We studied the prevalence of MVP using a large echocardiographic database.

METHOD

We retrospectively analyzed 24,265 echocardiograms performed between 1984 and 1998 for clinical reason. The total prevalence of MVP was calculated and stratified based on gender.

RESULTS

The database included 12,926 female and 11,339 male patients. The echocardiographic prevalence of MVP was 0.4% in females and 0.7% in males. The prevalence was 0.6% overall.

CONCLUSION

In the largest sample studied to date, the prevalence of MVP was lower than what was previously reported, with similar findings in both genders.

Mitral valvar prolapse is significantly associated with low body mass index in addition to mitral and tricuspid regurgitation

INTRODUCTION

An association between mitral valvar prolapse and low body mass index has been proposed. The goal of this study was to evaluate this suggested association using two independent and large databases. For comparison, we evaluated the association, if any, between bicuspid aortic valve and low body mass index.

METHODS

We retrospectively analyzed, using uni- and multivariate analysis, 1742 echocardiograms that were performed as a part of a cardiac screening of teenage athletes and 24,265 echocardiograms performed between 1984 and 1998 for various clinical indications.

RESULTS

The first database included a total of 12,926 (53%) female and 11,339 (47%) male patients. The second database included a total of 1172 male (67%) and 570 female (33%) high school athletes. Mitral valvar prolapse was independently associated with low body mass index in addition to mitral regurgitation in both data bases. An index less than 30 occurred in 78 of 13,874 (0.6%) as opposed to 7 of 3236 (0.2%) in the echo data base, p equal to 0.03, odds ratio: 2.4 confidence intervals: 1.1-5.2, and an index less than 20 occurred in 7 of 354 (2%) as opposed to 6 of 944 (0.6%) in the athletic data base, p equal to 0.03, odds ratio: 3.2 confidence intervals: 1.05-9.5. The finding of a bicuspid aortic valve did not have any association with low body mass index.

CONCLUSION

In our two independent databases, mitral valvar prolapse was independently associated with low body mass index in addition to mitral and tricuspid regurgitation. The cause of this association remains unknown.

Prevalence and clinical correlates of isolated mitral, isolated aortic regurgitation, and both in adults aged 21 to 35 years (from the CARDIA study)

Aortic regurgitation (AR) and mitral regurgitation (MR) can result in serious clinical complications and death. The physiologic and clinical correlates of AR and MR in a free-living young adult population, however, have not been well defined. The prevalence and correlates of AR and MR were investigated in Coronary Artery Risk Development in Young Adults (CARDIA), a multicenter National Heart, Lung, and Blood Institute study of 4,352 men and women aged 21 to 35 years who had 2-dimensionally directed M-mode echocardiographic and spectral and color Doppler examinations. Isolated MR by color Doppler was detected in 10.4% (90.4% with trivial or mild severity). Isolated AR by color Doppler was present in 0.8% (37.7% with mild severity). Combined AR and MR occurred in 0.5%. There was no association between body mass index and the prevalence or severity of MR or AR. Left ventricular mass was greater in subjects with isolated AR (mean +/- SD 172 +/- 49 g) than in those with MR (155 +/- 48 g) and greater in both groups than in subjects without MR and AR (148 +/- 44 g). AR was associated with increased aortic root diameter, whereas subjects with isolated MR and those with AR and MR had increased left atrial dimensions and greater left ventricular internal dimensions. In conclusion, MR and AR detected by color Doppler echocardiography are relatively uncommon in a healthy young adult population, but both are associated with evidence of increased left ventricular dimensions and mass.

Lone atrial fibrillation: Pathologic or not?

Atrial fibrillation risk has been strongly associated with increasing age and visceral obesity. These characteristics are strongly associated with diabetes, decreased heart rate variability, and chronic inflammation. Lone atrial fibrillation (LAF) on the other hand exhibits a predilection for the physically fit and the middle aged, especially males. Given these opposing features it is postulated that pathologic AF is due to cardiac fibrosis and other age related changes while LAF is due to physiologic neurohormonal changes related to autonomic tone, insulin sensitivity, and electrolyte imbalance and that pathologic AF and LAF can be reliably differentiated via an anthropometric approach using weight, height, hip, and waist measurements. An anthropometric study is undertaken from an LAF database to test this hypothesis. Such individuals in addition to being younger and predominantly male appear to be taller with less central adiposity vs. those with pathologic AF. The ramifications of these findings with respect to insulin resistance, sympathetic tone, inflammation and hypertension, often associated with pathologic atrial fibrillation, are discussed. Speculation is drawn about possible etiologic link with mitral valve prolapse, which is commonly encountered in the tall and thin and which shares multiple clinical features with LAF.

Adult women with mitral valve prolapse are more flexible

BACKGROUND

Mitral valve prolapse (MVP) is common in women. Other clinical features such as flexibility and hyperlaxity are often associated with MVP, as there is a common biochemical and histological basis for collagen tissue characteristics, range of joint motion, and mitral leaflet excursion.

OBJECTIVE

To confirm whether adult women with MVP are more flexible and hypermobile than those without.

METHODS

Data from 125 women (mean age 50 years), 31 of them with MVP, were retrospectively analysed with regard to clinical and kinanthropometric aspects. Passive joint motion was evaluated in 20 body movements using Flexitest and three laxity tests. Flexitest individual movements (0 to 4) and overall Flexindex scores were obtained in all subjects by the same investigator.

RESULTS

Women with MVP were lighter, less endomorphic and mesomorphic, and more linear. The Flexindex was significantly higher in the women with MVP, both absolute (48 (1.6) v 41 (1.3); p<0.01) and centile for age (67 v 42; p<0.01) values. In 13 out of 20 movements, the Flexitest scores were significantly higher for the women with MVP. Signs of hyperlaxity were about five times more common in these women: 74% v 16% (p<0.01). Scores of 0 and 1 in elbow extension, absence of hyperlaxity, and a Flexindex centile below 65 were almost never found in women with MVP.

CONCLUSION

Flexitest, alone or combined with hyperlaxity tests, may be useful in the assessment of adult women with MVP.

Mitral valve prolapse

Mitral valve prolapse is a common valvular abnormality that is the most common cause of severe non-ischaemic mitral regurgitation in the USA. The overall prognosis of patients with mitral valve prolapse is excellent, but a small subset will develop serious complications, including infective endocarditis, sudden cardiac death, and severe mitral regurgitation. We present a comprehensive review of mitral valve prolapse, examining normal mitral anatomy, the clinical and echocardiographic features of mitral valve prolapse, and the pathophysiology and genetics of the disorder. We discuss the contemporary management of both asymptomatic and symptomatic prolapse, with particular attention to the timing and technique of surgical repair. We conclude that echocardiography is the method of choice for diagnosing mitral valve prolapse, that clinical and echocardiographic features can predict which patients with prolapse are at highest risk for complications, and that mitral valve repair is the treatment of choice for symptomatic prolapse.

Panic disorder

BACKGROUND

This article reviews the clinical features, epidemiology, pathophysiology, dental findings, and dental and medical management of the care of patients with panic disorder, or PD.

TYPES OF STUDIES REVIEWED

The authors conducted a MEDLINE search for the period 1998 through 2003, using the key term "panic disorder" to define the pathophysiology of the disorder, its epidemiology and dental implications. The articles they selected for further review included those published in peer-reviewed journals.

RESULTS

PD is a common and debilitating psychiatric disease in which a person experiences sudden and unpredictable panic attacks, or PAs, with symptoms of overwhelming anxiety, chest pain, palpitations and shortness of breath. Persistent concern about having another attack and worry that it may indicate a heart attack or "going crazy" impairs the person's social, family and working lives. Frequently accompanying the disorder is agoraphobia, depression and mitral valve prolapse, or MVP.

CLINICAL IMPLICATIONS

In patients with PD, the prevalence of dental disease may be extensive because of the xerostomic effects of psychiatric medications used to treat it. Dental treatment consists of preventive dental education and prescribing saliva substitutes and anticaries agents. Precautions must be taken when prescribing or administering analgesics, antibiotics or sedative agents that may have an adverse interaction with the psychiatric medications. Because there is a connection between PAs and MVP, the dentist needs to consult with the patient's physician to determine the presence of MVP and whether there is associated mitral valve regurgitation. Patients with MVP and accompanying mitral valve regurgitation require prophylactic antibiotics when undergoing dental procedures known to cause a bacteremia and heightened risk of endocarditis.

Natural history of asymptomatic mitral valve prolapse in the community

BACKGROUND

The outcome of mitral valve prolapse (MVP) is controversial, with marked discrepancies in reported complication rates.

METHODS AND RESULTS

We conducted a community study of all Olmsted County, Minn, residents first diagnosed with asymptomatic MVP between 1989 and 1998 (N=833). Diagnosis, motivated by auscultatory findings (n=557) or incidental (n=276), was always confirmed by echocardiography with the use of current criteria. End points analyzed during 4581 person-years of follow-up were mortality (n=96, 19+/-2% at 10 years), cardiovascular morbidity (n=171), and MVP-related events (n=109, 20+/-2% at 10 years). The most frequent primary risk factors for cardiovascular mortality were mitral regurgitation from moderate to severe (P=0.002, n=131) and, less frequently, ejection fraction <50% (P=0.003, n=31). Secondary risk factors independently predictive of cardiovascular morbidity were slight mitral regurgitation, left atrium > or =40 mm, flail leaflet, atrial fibrillation, and age > or =50 years (all P<0.01). Patients with only 0 or 1 secondary risk factor (n=430) had excellent outcome, with 10-year mortality of 5+/-2% (P=0.17 versus expected), cardiovascular morbidity of 0.5%/y, and MVP-related events of 0.2%/y. Patients with > or =2 secondary risk factors (n=250) had mortality similar to expected (P=0.20) but high cardiovascular morbidity (6.2%/y, P<0.01) and notable MVP-related events (1.7%/y, P<0.01). Patients with primary risk factors (n=153) showed excess 10-year mortality (45+/-9%, P=0.01 versus expected), high morbidity (18.5%/y, P<0.01), and high MVP-related events (15%/y, P<0.01).

CONCLUSIONS

Natural history of asymptomatic MVP in the community is widely heterogeneous and may be severe. Clinical and echocardiographic characteristics allow separation of the majority of patients with excellent prognosis from subsets of patients displaying, during follow-up, high morbidity or even excess mortality as direct a consequence of MVP.

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.

The long-term outcome of mitral valve repair for mitral valve prolapse

The rationale of early surgery for severe chronic mitral regurgitation (MR) due to mitral valve prolapse (MVP) has been developed over the past decade on the basis of the understanding of the natural history of this disease and the predictors of outcomes after surgical correction of MR. The important decrease in operative mortality associated with the advancements in myocardial preservation, and more importantly the improved reparability of the myxomatous mitral valve, were an additional incentive to develop the concept of early surgery. Previous studies showed that mitral valve repair offers a survival advantage at short- and 10-year follow-up, and therefore suggested that it should be the treatment of choice for severe MR due to MVP. Moreover, very recent data provided new insight on the very long-term follow up, ie, beyond the usual first 10 years in which the initial survival benefit of repair may be negated by a late deterioration.