Prevalence of mitral valve prolapse in normal children

Echocardiographic Assessment of Mitral Valve Prolapse Prevalence before and after the Year 1999: A Systematic Review

Background: Over the last five decades, a fair number of echocardiographic studies have evaluated the prevalence of mitral valve prolapse (MVP) in various cohorts of individuals, including heterogeneous study populations. The present systematic review has been primarily designed to summarize the main findings of these studies and to estimate the overall MVP prevalence in the general community. Methods: All echocardiographic studies assessing the MVP prevalence in various cohorts of individuals, selected from PubMed and EMBASE databases, were included. There was no limitation of time period. The risk of bias was assessed by using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: The full texts of 21 studies with 1354 MVP individuals out of 63,723 participants were analyzed. The overall pooled prevalence of MVP was 4.9% (range of 0.6-21%). When dividing the studies in two groups according to the echocardiographic criteria used for MVP diagnosis (less specific old criteria or more specific new criteria, respectively), the estimated pooled prevalence of MVP was 7.8% (range of 2-21%) for the older studies (performed between 1976 and 1998) and 2.2% (range of 0.6-4.2%) for the more recent ones (conducted between 1999 and 2021). Potential selection bias, hospital- or referral-based series, and the use of less specific echocardiographic criteria for MVP diagnosis have been indicated as the main reasons for the higher MVP prevalence detected by the older studies. MVP was commonly associated with a narrow antero-posterior thoracic diameter, isolated ventricular premature beats and nonspecific ST-T-wave abnormalities on a resting electrocardiogram, mild-to-moderate mitral regurgitation (MR), the reduced probability of obstructive coronary artery disease, and a low frequency of serious complications, such as severe MR, infective endocarditis, heart failure, stroke, and atrial fibrillation. Conclusions: MVP has a low prevalence in the general population, regardless of age, gender, and ethnicity, and is associated with a good outcome.

The evolving role of cardiovascular magnetic resonance in the assessment of mitral valve prolapse

Mitral valve prolapse (MVP), characterized by a displacement > 2 mm above the mitral annulus of one or both bileaflets, with or without leaflet thickening, is a common valvular heart disease, with a prevalence of approximately 2% in western countries. Although this population has a generally good overall prognosis, MVP can be associated with mitral regurgitation (MR), left ventricular (LV) remodeling leading to heart failure, ventricular arrhythmia, and, the most devastating complication, sudden cardiac death, especially in myxomatous bileaflet prolapse (Barlow's disease). Among several prognostic factors reported in the literature, LV fibrosis and mitral annular disjunction may act as an arrhythmogenic substrate in this population. Cardiac magnetic resonance (CMR) has emerged as a reliable tool for assessing MVP, MR severity, LV remodeling, and fibrosis. Indeed, CMR is the gold standard imaging modality to assess ventricular volume, function, and wall motion abnormalities; it allows accurate calculation of the regurgitant volume and regurgitant fraction in MR using a combination of LV volumetric measurement and aortic flow quantification, independent of regurgitant jet morphology and valid in cases of multiple valvulopathies. Moreover, CMR is a unique imaging modality that can assess non-invasively focal and diffuse fibrosis using late gadolinium enhancement sequences and, more recently, T1 mapping. This review describes the use of CMR in patients with MVP and its role in identifying patients at high risk of ventricular arrhythmia.

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.

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.

Cardiac Imaging for Risk Assessment of Malignant Ventricular Arrhythmias in Patients With Mitral Valve Prolapse

Recent studies have described the occurrence of complex ventricular arrhythmias and sudden cardiac death among patients with mitral valve prolapse (MVP). The reported incidence rate of sudden cardiac death or ventricular tachycardia is about 1–1.5% among patients with MVP. Various imaging markers have been associated with this increased risk, including mitral annular disjunction, replacement fibrosis by late gadolinium enhancement, and mechanical dispersion. In this review, we briefly discuss how multimodality cardiac imaging can be applied to identify MVP patients with high risk of sudden cardiac death and complex ventricular arrhythmias.

Echocardiographic screening for mitral valve prolapse in Turkish school children

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

International consensus statement on the diagnosis and management of autosomal dominant polycystic kidney disease in children and young people

These recommendations were systematically developed on behalf of the Network for Early Onset Cystic Kidney Disease (NEOCYST) by an international group of experts in autosomal dominant polycystic kidney disease (ADPKD) from paediatric and adult nephrology, human genetics, paediatric radiology and ethics specialties together with patient representatives. They have been endorsed by the International Pediatric Nephrology Association (IPNA) and the European Society of Paediatric Nephrology (ESPN). For asymptomatic minors at risk of ADPKD, ongoing surveillance (repeated screening for treatable disease manifestations without diagnostic testing) or immediate diagnostic screening are equally valid clinical approaches. Ultrasonography is the current radiological method of choice for screening. Sonographic detection of one or more cysts in an at-risk child is highly suggestive of ADPKD, but a negative scan cannot rule out ADPKD in childhood. Genetic testing is recommended for infants with very-early-onset symptomatic disease and for children with a negative family history and progressive disease. Children with a positive family history and either confirmed or unknown disease status should be monitored for hypertension (preferably by ambulatory blood pressure monitoring) and albuminuria. Currently, vasopressin antagonists should not be offered routinely but off-label use can be considered in selected children. No consensus was reached on the use of statins, but mTOR inhibitors and somatostatin analogues are not recommended. Children with ADPKD should be strongly encouraged to achieve the low dietary salt intake that is recommended for all children.

The incidence of Marfan syndrome and cardiac anomalies in patients presenting with pectus deformities

PURPOSE

The incidence of Marfan syndrome in the general population is 0.3%. Two-thirds of patients with Marfan syndrome have concurrent pectus deformity. However, incidence of Marfan syndrome and cardiac abnormalities in patients presenting with an isolated pectus deformity remains unknown. We sought to establish the degree of association between pectus deformities and these abnormalities, and whether referral of these patients for cardiac and genetic workup is warranted.

METHODS

Our pediatric surgery group refers patients with pectus deformities for genetic and cardiac evaluation. We examined 415 records from 2009 to 2016, and identified 241 patients with a chief complaint of a pectus deformity. Patient characteristics, echocardiogram results, Haller indices, and genetic results were analyzed.

RESULTS

The frequency of Marfan syndrome in our study was 5.3%. The incidence of Marfan was highest among patients with combined type pectus deformity (20%). Cardiac anomalies showed an overall incidence of 35%. Of those diagnosed with Marfan, 84% had cardiac abnormalities.

CONCLUSION

More than 5% of patients presenting with a chief complaint of pectus deformity will have a diagnosis of Marfan syndrome, compared to 0.3% in the general population. Approximately a third of this population will have cardiac abnormalities. Referral of patients with pectus deformities for evaluation for Marfan syndrome and cardiac abnormalities is appropriate.

LEVEL OF EVIDENCE

Level IV.

Handheld echocardiography for screening and control of rheumatic heart disease study in Gezira state, Sudan: a double approach model

Background

Rheumatic heart disease (RHD) is prevalent in Sudan's rural areas including Gezira state in central Sudan. We initiated a control program aiming at measurement of the echocardiographic (echo) prevalence of RHD, training of health workers and public awareness.

Methods

This is a cross-sectional and interventional study conducted in Gezira State, Al Managil Locality from Nov 2016 to February 2018. We used handheld echo (HHE) to detect the prevalence of RHD in school children and those tested positives were referred for standard echo. In addition, training on detection of RHD for health professionals was offered using training modules for physicians and nurses. Evaluation of health facilities was carried out using a questionaire. This was coupled with educational sessions to increase public awareness about RHD using posters and pamphlets.

Results

Two thousand and one hundred twenty-nine school children were screened, 36 cases were positive by HHE, out of these 31 underwent standard echo and 5 were confirmed to have RHD, giving an echo prevalence of 2.3/1,000. All cases had mild mitral regurgitation. Knowledge, attitudes and practices of 175 health workers were assessed then a tailored training program was implemented. Practices that are not compatible with Sudan's RHD Guidelines were detected including performing skin testing prior to administration of benzathine penicillin and under-utilization of local anesthetic to decrease the pain when giving the injection. Benzathine penicillin was available in only 32% of health facilities and only 25% of their personnel received training in RHD management.

Conclusions

RHD echo prevalence in Gezira is relatively high and the health system needs to be strengthened. A double approach, screen-to-control program that utilizes HHE screening, health workers' training, public awareness and providing medical supplies in primary health care centers is feasible.

A manifesto for cardiovascular imaging: addressing the human factor

Our use of modern cardiovascular imaging tools has not kept pace with their technological development. Diagnostic errors are common but seldom investigated systematically. Rather than more impressive pictures, our main goal should be more precise tests of function which we select because their appropriate use has therapeutic implications which in turn have a beneficial impact on morbidity or mortality. We should practise analytical thinking, use checklists to avoid diagnostic pitfalls, and apply strategies that will reduce biases and avoid overdiagnosis. We should develop normative databases, so that we can apply diagnostic algorithms that take account of variations with age and risk factors and that allow us to calculate pre-test probability and report the post-test probability of disease. We should report the imprecision of a test, or its confidence limits, so that reference change values can be considered in daily clinical practice. We should develop decision support tools to improve the quality and interpretation of diagnostic imaging, so that we choose the single best test irrespective of modality. New imaging tools should be evaluated rigorously, so that their diagnostic performance is established before they are widely disseminated; this should be a shared responsibility of manufacturers with clinicians, leading to cost-effective implementation. Trials should evaluate diagnostic strategies against independent reference criteria. We should exploit advances in machine learning to analyse digital data sets and identify those features that best predict prognosis or responses to treatment. Addressing these human factors will reap benefit for patients, while technological advances continue unpredictably.

Mitral Valve Prolapse: Multimodality Imaging and Genetic Insights

Mitral valve prolapse (MVP) is a common heritable valvulopathy affecting approximately 2.4% of the population. It is the most important cause of primary mitral regurgitation (MR) requiring surgery. MVP is characterized by fibromyxomatous changes and displacement of one or both mitral leaflets into the left atrium. Echocardiography represents the primary diagnostic modality for assessment of MVP. Accurate quantitation of ventricular volumes and function for surgical planning in asymptomatic severe MR can be provided with both echocardiography and cardiac magnetic resonance. In addition, assessment of myocardial fibrosis using late gadolinium enhancement and T1 mapping allows better understanding of the impact of MVP on the myocardium. Imaging in MVP is important not only for diagnostic and prognostic purposes, but is also essential for detailed phenotyping in genetic studies. Genotype-phenotype studies in MVP pedigrees have allowed the identification of milder, non-diagnostic MVP morphologies by echocardiography. Such morphologies represent early expression of MVP in gene carriers. This review focuses on multimodality imaging and the phenotypic spectrum of MVP. Moreover, the review details the recent genetic discoveries that have increased our understanding of the pathophysiology of MVP, with clues to mechanisms and therapy.

The association between systemic lupus erythematosus and valvular heart disease: an extensive data analysis

BACKGROUND

Association between antiphospholipid syndrome in systemic lupus erythematosus (SLE) and valvular heart disease (VHD) is well reported, but relatively few studies have been carried out to establish the linkage between VHD and SLE itself. We aimed to investigate link between VHD and SLE and to evaluate the association of diverse factors with VHD among these patients in a large-scale population-based study.

MATERIALS AND METHODS

We used the databases of the largest state-mandated health service organization in Israel. All SLE patients were included (n = 5018) as well as their age and sex-matched controls (n = 25 090), creating a cross-sectional population-based study. Medical records of all subjects were analysed for documented VHD and the presence of antiphospholipid antibodies (aPLs). A logistic regression model was carried out to evaluate the diverse factors including SLE and aPLs as independent risk factors for VHD.

RESULTS

Valvular heart disease were found to be more frequent among SLE group when compared to controls (aortic stenosis, 1·08% vs. 0·35% respectively, P < 0·001; aortic insufficiency, 1·32% vs. 0·29% respectively, P < 0·001; mitral stenosis, 0·74% vs. 0·21% respectively, P < 0·001; mitral insufficiency, 1·91% vs. 0·39% respectively, P < 0·001). Male sex, hypertension, aPLs and SLE were found to be significant independent risk factors for VHD.

CONCLUSION

All VHD are more prevalent among SLE patients when compared to controls. SLE and aPLs are independent risk factor for VHD (OR of 2·46 and 1·7, respectively). Physicians must be aware of such significant association, and routine echocardiography should be considered in SLE patients regardless of their aPL status.

Piezogenic Pedal Papules with Mitral Valve Prolapse

Piezogenic pedal papules (PPP) are herniations of subcutaneous adipose tissue into the dermis. PPP are skin-colored to yellowish papules and nodules on lateral surfaces of feet that typically become apparent when the patient stands flat on his/her feet. Some connective tissue diseases and syndromes have been reported in association with PPP. Mitral valve prolapse (MVP) is a myxomatous degeneration of the mitral valve, characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. MVP may be isolated or part of a heritable connective tissue disorder. PPP, which is generally considered as an isolated lesion, might be also a predictor of some cardiac diseases associated with connective tissue abnormalities such as MVP. A detailed systemic investigation including cardiac examination should be done in patients with PPP. Since in the literature, there are no case reports of association of PPP with MVP, we report these cases.

Imaging of Mitral Valve Prolapse: What Can We Learn from Imaging about the Mechanism of the Disease?

Mitral valve prolapse (MVP) is the most common mitral valve disorder affecting 2%-3% of the general population. Two histological forms for the disease exist: Myxomatous degeneration and fibroelastic disease. Pathological evidence suggests the disease is not confined solely to the valve tissue, and accumulation of proteoglycans and fibrotic tissue can be seen in the adjacent myocardium of MVP patients. MVP is diagnosed by demonstrating valve tissue passing the annular line into the left atrium during systole. In this review we will discuss the advantages and limitations of various imaging modalities in their MVP diagnosis ability as well as the potential for demonstrating extra associated valvular pathologies.

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.

Does the association between mitral valve prolapse and panic disorder really exist?

OBJECTIVE

Although the possible relationship between panic disorder and mitral valve prolapse (MVP) attracted considerable research interest in the 1980s and 1990s, the reported prevalence of MVP in these patients has been inconsistent and widely variable. Clinical and epidemiologic studies have produced controversial data on possible association or definite causal relationship between these 2 entities. The primary objective of the present review was to summarize the current state of knowledge on the association between panic disorder and MVP, including the influence of diagnostic criteria for MVP on the controversial results.

DATA SOURCES

We searched MEDLINE, LILACS, and EMBASE databases using the keywords panic and mitral. Inclusion criteria were articles concerning the reciprocal association of MVP and panic disorder, published from the earliest dates available through December 2006.

STUDY SELECTION

All relevant articles published in English, Spanish, or Portuguese and reporting original data related to the association of MVP and panic disorder were included. Forty articles fulfilling the criteria for inclusion in this review were identified.

DATA SYNTHESIS

Even though the reported prevalence of MVP in panic disorder varied from 0% to 57%, a significant association between the 2 disorders was documented in 17 of the 40 studies. Such inconsistent results were due to sampling biases in case or control groups, widely different diagnostic criteria for MVP, and lack of reliability of MVP diagnosis. None of the reviewed studies used the current state-of-the-art diagnostic criteria for MVP to evaluate the volunteers. Apparently, the more elaborate the study methodology, the lower the chance to observe a significant relationship between these 2 conditions.

CONCLUSIONS

Published results are insufficient to definitely establish or to exclude an association between MVP and panic disorder. If any relationship does actually exist, it could be said to be infrequent and mainly occur in subjects with minor variants of MVP. To clarify this intriguing issue, future studies should mainly focus on the observed methodological biases and particularly should use the current criteria for MVP as the standard for evaluation.

Indications and technique of Nuss procedure for pectus excavatum

Pectus excavatum most frequently involves the lower sternum and chest wall. Because the morphology varies, preoperative imaging for anatomic assessment and documentation of dimensions of the chest are important. Many modifications have been made to the minimally invasive procedure since it was first performed in 1987. As a result, there has been an increase in the number of patients seeking surgical correction. This article discusses the clinical features of pectus excavatum and reviews the preoperative considerations and the steps involved in the repair of the deformity.

Pectus excavatum: historical background, clinical picture, preoperative evaluation and criteria for operation

Pectus excavatum is a depression of the sternum and costal cartilages which may present at birth, or more commonly during the teenage growth spurt. Symptoms of lack of endurance, shortness of breath with exercise, or chest pain are frequent. Although pectus excavatum may be a component of some uncommon syndromes, patients usually are healthy. Evaluation should include careful anatomic description with photographs, radiography to demonstrate the depth of the depression, extent of cardiac compression, or displacement, measurement of pulmonary function, and echocardiography to look for mitral valve prolapse (in 15%) or diminished right ventricular volume. Indications for surgical treatment include two or more of the following: a severe, symptomatic deformity; progression of deformity; paradoxical respiratory chest wall motion; computer tomography scan with a pectus index greater than 3.25; cardiac compression/displacement and/or pulmonary compression; pulmonary function studies showing restrictive disease; mitral valve prolapse, bundle branch block, or other cardiac pathology secondary to compression of the heart; or failed previous repair(s). The developmental factors, genetics, and physiologic abnormalities associated with the condition are reviewed.

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.

Children with chest pain visiting the emergency department

BACKGROUND

Chest pain is a common complaint in children visiting the emergency department (ED). True organic problems like cardiac disease are rare. We assess and analyze the etiology of chest pain among children visiting a pediatric ED in one medical center.

METHODS

We retrospectively reviewed the medical records of children with chest pain who visited our ED between September 2002 and June 2005. Any case of trauma-associated chest pain was excluded from this study.

RESULTS

A total of 103 patients (64 boys, 39 girls; mean age, 13 years; age range, 4-17 years) were enrolled into this study; 101 patients had chest radiograms (98.1%). Pneumonia was identified in five patients and pneumothorax in three. Eighty-seven patients had electrocardiogram study (84.5%) and four of them showed abnormalities. Additional diagnostic tests were performed in 64 patients (62.1%), including complete blood count analysis and echocardiography. Echocardiograms were performed in 15 (14.6%) patients. Six of them showed minor abnormality. Panendoscopy was done in six (5.8%) patients, and gastroesophageal reflux was found in three. Eleven (10.7%) patients were admitted to hospital because of pneumonia, pneumothorax or arrhythmia. Overall, idiopathic chest pain was the most common diagnosis (59.2%). Other associated disorders were pulmonary (24.3%), musculoskeletal (6.7%), gastrointestinal (5.8%), cardiac (2.0%) and miscellaneous (2.0%).

CONCLUSION

The most common cause of chest pain prompting a child to visit the ED is idiopathic chest pain. Careful physical examination can reveal important clues and save much unnecessary examinations.

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.

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.

Molecular genetics of mitral valve prolapse

PURPOSE OF REVIEW

Mitral valve prolapse is a common disorder with a strong hereditary component. It is associated with important mitral regurgitation requiring surgical repair and other clinical complications. Genetic studies can provide clues to mechanism and therapy.

RECENT FINDINGS

Advances in phenotypic classification have led to linkage to sites on chromosomes 11, 13 and 16 and identification of the first mutation in familial mitral valve prolapse not related to connective tissue syndromes - an X-linked filamin A mutation. New understanding of mechanism based on studies in a mouse Marfan model emphasize the dynamic interplay of differentiating cells and growth factors, with strong potential for therapy.

SUMMARY

This new knowledge brings us closer to the ultimate goal of preventing the progression of mitral valve disease to the stage of clinical expression.

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.

Mitral valve prolapse: now you see it; now you don't: recalling the discovery, rise and decline of a diagnosis

Mitral valve prolapse has been recognized as a clinical entity for only the past 50 years, although the auscultatory findings of this condition had been recognized since the mid-19th century. On the evidence of only a few autopsies, it was concluded that the basis for these were pleuropericardial adhesions. Left ventricular angiographic studies performed in the 1960s clearly documented the true nature of the condition, although it was not until the advent of echocardiography that large numbers of patients began to be referred for evaluation by this new technique. Because of the wide variety of symptoms in patients with suspected mitral valve prolapse, similar to those with other conditions, many patients with the latter were referred for evaluation and diagnosed with mitral valve prolapse because of misleading M-mode and then 2-dimensional criteria. It is now recognized, with the use of improved, more restrictive echocardiographic criteria, that the prevalence of the disorder is much less than previously believed. No test has been devised that will prove 100% sensitive and 100% specific for any disorder. In conclusion, this sobering fact should encourage the use of all modalities available, including clinical skills, to make proper diagnoses when these may be in doubt.

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.

Temporal variability in birth prevalence of congenital heart defects as recorded by a general birth defects registry

OBJECTIVE

Our aim was to examine the temporal variability in congenital heart defect (CHD) birth prevalence from 1980 to 2000 in Emilia-Romagna, Italy.

METHODS

The study population consisted of all infants, surveyed by the Emilia-Romagna birth defects registry (Indagine Malformazioni conpenite in Emilia-Romagna [IMER]), who were affected by CHDs. A simplified classification into "simple" and "complex " CHD was adopted. A comparison with another epidemiologic study using different methodology in the same area was performed.

RESULTS

From 1980 to 2000, IMER ascertained 2442 live births with CHD of 480,793 infants born, with an average CHD birth prevalence of 5.1% (Range, 3.1% to 7.5%). A significant increase in prevalence of simple CHD during the second decade of the study was demonstrated because of an increased recognition of "minor" cardiac lesions among the simple CHD. The birth prevalence of complex CHD remained stable.

CONCLUSIONS

The apparent increase in live births with CHD results mainly from the current widespread availability of color Doppler echocardiography, which allows the early detection of the "minor" cardiac defects. Other differences are the result of the sources of ascertainment, diagnostic criteria, system of classification, and especially the age limit for enrolling infants with suspected CHD.

JS, Dai D, Leyne M, Marshall JE, Nesta F, Levine RA, Slaugenhaupt SA. A locus for autosomal dominant mitral valve prolapse on chromosome 11p15.4

Mitral valve prolapse (MVP) is a common cardiovascular abnormality in the United States, occurring in approximately 2.4% of the general population. Clinically, patients with MVP exhibit fibromyxomatous changes in one or both of the mitral leaflets that result in superior displacement of the leaflets into the left atrium. Although often clinically benign, MVP can be associated with important accompanying sequelae, including mitral regurgitation, bacterial endocarditis, congestive heart failure, atrial fibrillation, and even sudden death. MVP is genetically heterogeneous and is inherited as an autosomal dominant trait that exhibits both sex- and age-dependent penetrance. In this report, we describe the results of a genome scan and show that a locus for MVP maps to chromosome 11p15.4. Multipoint parametric analysis performed by use of GENEHUNTER gave a maximum LOD score of 3.12 for the chromosomal region immediately surrounding the four-marker haplotype D11S4124-D11S2349-D11S1338-D11S1323, and multipoint nonparametric analysis (NPL) confirms this finding (NPL=38.59; P=.000397). Haplotype analysis across this region defines a 4.3-cM region between the markers D11S1923 and D11S1331 as the location of a new MVP locus, MMVP2, and confirms the genetic heterogeneity of this disorder. The discovery of genes involved in the pathogenesis of this common disease is crucial to understanding the marked variability in disease expression and mortality seen in MVP.

Prevalence of mitral valve prolapse in Stickler syndrome

The prevalence of mitral valve prolapse in Stickler syndrome has been reported to be much higher than in the general population. As a result, it has been recommended that all patients with Stickler syndrome undergo routine echocardiography and have antibiotic prophylaxis prior to surgery. The purpose of this study was to evaluate the prevalence of mitral valve prolapse in a large cohort of UK patients with Stickler syndrome in whom the clinical diagnosis has been confirmed by molecular genetic analysis. Probands and pedigrees were identified from the Vitreoretinal Service database according to previously published criteria. Ophthalmic, skeletal, audiometric, and orofacial features were assessed. Affected individuals underwent a full cardiological examination including auscultation and two-dimensional echocardiography. Mutation analysis of the COL2A1 and COL11A1 genes was carried out. Seventy-eight patients from 25 pedigrees were studied. Mutation analysis confirmed the clinical diagnosis in every pedigree. No patient was found to have clinical evidence of cardiovascular disease and no patient had significant mitral or other valvular prolapse on echocardiography. These data from a large cohort of UK patients with proven Stickler syndrome do not suggest an increased incidence of mitral valve prolapse over and above that found in the general population. Routine echocardiography screening and use of preoperative antibiotics are unnecessary and should be reserved for those individual cases where there is clear clinical indication.

Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study

OBJECTIVE

The aim of this study was to examine the echocardiographic features and associations of mitral valve prolapse (MVP) diagnosed by current two-dimensional echocardiographic criteria in an unselected outpatient sample.

BACKGROUND

Previous studies of patients with MVP have emphasized the frequent occurrence of echocardiographic abnormalities such as significant mitral regurgitation (MR) and left atrial (LA) enlargement that are associated with clinical complications. These studies, however, have been limited by the use of hospital-based or referral series.

METHODS

We quantitatively studied all 150 subjects with possible MVP by echocardiography and 150 age- and gender-matched subjects without MVP from the 3,491 subjects in the Framingham Heart Study. Based on leaflet morphology, subjects were classified as having classic (n = 46), nonclassic (n = 37), or no MVP.

RESULTS

Leaflet length, MR degree, and LA and left ventricular size were significantly but mildly increased in MVP (p < 0.0001 to 0.004), with mean values typically within normal range. Average MR jet area was 15.1 +/- 1.4% (mild) in classic MVP and 8.9 +/- 1.5% (trace) in nonclassic MVP; MR was severe in only 3 of 46 (6.5%) subjects with classic MVP, and LA volume was increased in only 8.7% of those with classic MVP and 2.7% of those with nonclassic MVP.

CONCLUSIONS

Although the echocardiographic characteristics of subjects with MVP in the Framingham Heart Study differ from those without MVP, they display a far more benign profile of associated valvular, atrial, and ventricular abnormalities than previously reported in hospital- or referral-based series. Therefore, these findings may influence the perception of and approach to the outpatient with MVP.

Diminished global fibrinolytic capacity in patients with mitral valve prolapse is associated with transient ischemic attacks

Although mitral valve prolapse (MVP) has shown to be associated with thromboembolic complications, the cause of thromboembolic events in those patients is still unknown. The purpose of this study was to evaluate the fibrinolytic activity in MVP patients. The study included 35 consecutive patients (25 women, mean age 25+/-11 years) with echocardiographically documented MVP and 25 age- and sex-matched subjects as a control group. Four of MVP patients have a history of transient ischemic attack (TIA). Global fibrinolytic capacity (GFC), a new technique that examines the effectiveness of the entire fibrinolytic system, was measured. Global fibrinolytic capacity was found to be nonsignificantly increased in MVP patients (3.14+/-1.42 microg/mL) compared to those in control subjects (2.36+/-1.33 microg/mL) (p>0.05). However, in four of these MVP patients who had a history of transient ischemic attack, the GFC level was significantly lower than in patients who have no history of transient ischemic attack (1.67+/-0.6 microg/mL vs 3.27+/-1.46 (microg/mL, p=0.003). Furthermore, the GFC levels of these four patients were less than those of controls (p=0.04). These results showed that global fibrinolytic activity was similar in MVP patients without a history of TIA and control subjects. However, MVP patients with a history of TIA had significantly decreased global fibrinolytic activity compared to controls and as well as MVP patients without a history of TIA.

Supernumerary nipple as a cutaneous marker of mitral valve prolapse in Asian Indians

We studied 68 Asian Indians from South India with supernumerary nipple (SN) and 49 age- and sex- matched controls without SN for evidence of mitral valve prolapse (MVP) and associated features. We found that MVP and its forme fruste were more common in the SN group (odds ratio 6.0, 95% confidence intervals 2.16 to 16.63), indicating an association of SN with MVP.

Comparative study of clinical evaluation of heart murmurs by general pediatricians and pediatric cardiologists

In a study to compare the clinical diagnostic skills of academic general pediatricians and academic pediatric cardiologists in the evaluation of heart murmurs, a total of 128 patients (aged 1 month to 18 years) newly referred to a university pediatric cardiology clinic were evaluated by one of three general pediatricians and one of four pediatric cardiologists. The murmurs were clinically classified as innocent, pathologic, or possibly pathologic. The classification was revised after the review of electrocardiogram (EKG) and chest radiograph (CXR), if indicated. The definitive diagnosis was ascertained by echocardiography (94 normal, 34 abnormal). The general pediatricians identified as many pathologic heart murmurs as the pediatric cardiologists (27/34 vs. 29/34), with no difference in sensitivity, 79% vs. 85% (p = 0.53). The similarity in sensitivity could be because the general pediatricians were more cautious in the classification of heart murmurs and had classified more innocent heart murmurs as pathologic than the pediatric cardiologists (13/39 vs. 3/23), 41% vs. 13% (p = 0.02). The pediatric cardiologists correctly identified more innocent murmurs than general pediatricians (52/94 vs. 72/94), with a better specificity, 55% vs. 76% (p = 0.001); however, the accuracy of prediction of innocence was similar for both groups (52/59 vs. 72/77), 88% vs. 93% (p = 0.36). The revision of diagnosis with review of EKG and CXR was more often misleading than helpful for either group. Academic general pediatricians would identify most of the pathologic murmurs and are no more likely than an academic pediatric cardiologist to misclassify a pathologic heart murmur as innocent.

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

OBJECTIVE

To describe the epidemiology of echocardiographic mitral valve prolapse (MVP) and its anthropometric, physiologic, and psychobehavioral correlates with a cross-sectional analysis at 4 urban clinical centers.

PATIENTS

A biethnic, community-based sample of 4136 young (aged 23 to 35 years) adult participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study who had echocardiograms during their third examination between 1990 and 1991.

MEASUREMENTS

Echocardiographic mitral valve prolapse, Doppler mitral regurgitation, blood pressure, anthropometry, and 4 psychobehavioral scales.

RESULTS

Definite echocardiographic MVP prevalence was 0.6% overall and was similar across the 4 ethnicity/sex groups. Most participants (21 of 26, 80%) with definite echocardiographic MVP were unaware of their condition. Relative to persons with normal echocardiograms, those with echocardiographic MVP were taller (174.6 cm vs 171.0 cm, P <.01), leaner (26.7 mm vs 37.4 mm sum of triceps and subscapular skinfolds, P <.01), had lower body mass index (22.0 kg/m(2) vs 26.2 kg/m(2), P <.01), and more often has Doppler mitral regurgitation (34.8% vs 11. 8%, P <.01). Women with echocardiographic MVP had higher ethnicity-adjusted hostility scores (19.9 vs 16.1, P <.05) than women with no MVP. Among 111 (2.7%) of 4136 participants reporting prior physician diagnosis of MVP, only 5 (0.45%) of 111 had definite echocardiographic MVP.

CONCLUSIONS

These data document a low prevalence of definite echocardiographic MVP and suggest a constellation of anthropometric, physiologic, and psychobehavioral characteristics in young adults with echocardiographic MVP. Most definite echocardiographic MVP diagnoses were discordant with self-reported MVP status, and false-positive diagnoses of echocardiographic MVP were made more often in women and whites.

Lack of evidence of an association between mitral-valve prolapse and stroke in young patients

BACKGROUND

Previous studies have reported a high prevalence of mitral-valve prolapse among patients with embolic stroke (28 to 40 percent), especially among young patients (those < or =45 years old); this finding has practical implications for prophylaxis. However, diagnostic criteria for prolapse have changed and are now based on three-dimensional analysis of the shape of the valve; use of the current criteria reduces markedly the frequency of such a diagnosis and increases its specificity. Previously described complications must therefore be reconsidered.

METHODS

In a case-control study, we reviewed data on 213 consecutive patients 45 years old or younger with documented ischemic stroke or transient ischemic attack between 1985 and 1995; they underwent complete neurologic and echocardiographic evaluations. The prevalence of prolapse in these patients was compared with that in 263 control subjects without known heart disease, who were referred to our institution for assessment of ventricular function before receiving chemotherapy.

RESULTS

Mitral-valve prolapse was present in 4 of the 213 young patients with stroke (1.9 percent), as compared with 7 of the 263 controls (2.7 percent); prolapse was present in 2 of 71 patients (2.8 percent) with otherwise unexplained stroke. The crude odds ratio for mitral-valve prolapse among the patients who had strokes, as compared with those who did not have strokes, was 0.70 (95 percent confidence interval, 0.15 to 2.80; P=0.80); after adjustment for age and sex, the odds ratio was 0.59 (95 percent confidence interval, 0.12 to 2.50; P=0.62).

CONCLUSIONS

Mitral-valve prolapse is considerably less common than previously reported among young patients with stroke or transient ischemic attack, including unexplained stroke, and no more common than among controls. Using more specific and currently accepted echocardiographic criteria, therefore, we could not demonstrate an association between the presence of mitral-valve prolapse and acute ischemic neurologic events in young people.

Prevalence and clinical outcome of mitral-valve prolapse

BACKGROUND

Mitral-valve prolapse has been described as a common disease with frequent complications. To determine the prevalence of mitral-valve prolapse in the general population, as diagnosed with the use of current two-dimensional echocardiographic criteria, we examined the echocardiograms of 1845 women and 1646 men (mean [+/-SD] age, 54.7+/-10.0 years) who participated in the fifth examination of the offspring cohort of the Framingham Heart Study.

METHODS

Classic mitral-valve prolapse was defined as superior displacement of the mitral leaflets of more than 2 mm during systole and as a maximal leaflet thickness of at least 5 mm during diastasis, and nonclassic prolapse was defined as displacement of more than 2 mm, with a maximal thickness of less than 5 mm.

RESULTS

A total of 84 subjects (2.4 percent) had mitral-valve prolapse: 47 (1.3 percent) had classic prolapse, and 37 (1.1 percent) had nonclassic prolapse. Their age and sex distributions were similar to those of the subjects without prolapse. None of the subjects with prolapse had a history of heart failure, one (1.2 percent) had atrial fibrillation, one (1.2 percent) had cerebrovascular disease, and three (3.6 percent) had syncope, as compared with unadjusted prevalences of these findings in the subjects without prolapse of 0.7, 1.7, 1.5, and 3.0 percent, respectively. The frequencies of chest pain, dyspnea, and electrocardiographic abnormalities were similar among subjects with prolapse and those without prolapse. The subjects with prolapse were leaner (P<0.001) and had a greater degree of mitral regurgitation than those without prolapse, but on average the regurgitation was classified as trace or mild.

CONCLUSIONS

In a community based sample of the population, the prevalence of mitral-valve prolapse was lower than previously reported. The prevalence of adverse sequelae commonly associated with mitral-valve prolapse in studies of patients referred for that diagnosis was also low.

Is mitral valve prolapse a congenital or acquired disease?

The prevalence of mitral valve prolapse (MVP) at birth was studied in 1,734 consecutive newborns without congenital structural heart disease. We have not identified any case of an unequivocal pattern of MVP using auscultatory and echocardiographic diagnostic criteria. Our data argue for the concept that MVP is an acquired disease.

Platelet and blood clotting activation in patients with mitral valve prolapse

In patients with mitral valve prolapse (MVP) a high incidence of valvular abnormalities with a history of previous cerebrovascular disease has been reported and an embolic mechanism has been proposed. Aim of this study is the study of platelet and coagulation activation in patients with MVP. Fifty-four patients affected by MVP (mean age 46 +/- 15 yrs, 22 males, 32 females) and 50 control subjects, age- and sex-matched, were tested for platelet activation [P-selectin and GpIIb-IIIa platelet surface expression at rest and after stimuli by flow cytometric analysis, Beta-Thromboglobulin (TG) and Platelet Factor 4 (PF4) plasma levels by ELISA, platelet-rich-plasma (PRP) and whole blood spontaneous platelet aggregation (SPA)] and for activation of blood coagulation (Prothrombin activation fragment F1+2 plasma levels by ELISA). P-selectin, GpIIb-IIIa expression, Beta-TG, PF4 and SPA were found similar in MVP patients and in controls. However, in patients with severe mitral regurgitation (MR) the percentage of activated platelets which express P-selectin after stimuli was slightly but significantly (p < 0.05) lower in comparison to MVP patients without or with mild to moderate MR and to controls. Moreover, in patients with severe MR F1+2 levels (median 1.6 nmol/L, range 0.6-2.6 nmol/L) were significantly higher (p < 0.001) than both in controls (median 0.95 nmol/L, range 0.2-1.4 nmol/L) and in patients without or with mild to moderate MR (median 1.0 nmol/L, range 0.4-2.3 nmol/L). Our findings suggest that MVP is not responsible per se for blood clotting activation, but in patients with severe mitral insufficiency an increase in thrombin generation can occur. These alterations in hemostatic system may represent a mechanism by which MR increases the risk of thromboembolic events in patients with MVP.

Prevalence of bicuspid aortic valve and mitral valve prolapse in a healthy Saudi population and the clinical implications of their association

In this study, 103 Saudi males and 172 Saudi females were referred for medical check-up for employment purposes and/or as undergraduate students. Clinical evaluation of all participants included full cardiovascular examination, with the following investigations being performed: ECG, chest x-ray, and cross-sectional echocardiography. Bicuspid aortic valve was detected in three males and in four females, for a total percentage of 2.5%. Isolated mitral valve prolapse was detected in seven males (6.7%) and six females (3.5%). Association with mitral valve prolapse was reported in five males and seven females, with a total percentage of 4.3%. This association seems to have important etiological, medical and surgical implications.