Mitral valve prolapse تدلي أو هبوط الدسام التاجي
INSTRUCTION Examine this patient's heart. SALIENT FEATURES History · Palpitations associated with mild tachyarrhythmias. · Increased adrenergic symptoms. · Chest pain. · Anxiety or fatigue. Examination · Mid-systolic click tbllowed by late or mid-systolic murmur. Note. Squatting will bring the click closer to the second heart sound and decrease the duration of the murmur. A Valsalva manoeuvre and standing have the opposite effect. · Look for features of Marfan's syndrome (high-arched palate, arm span greater than height). DIAGNOSIS This patient has mitral valve prolapse (lesion) and a long pansystolic murmur, indicating significant mitral regurgitation which will require prophylaxis for infective endocarditis (functional status). QUESTIONS What are eponyms for mitral valve prolapse (MVP)? Barlow's syndrome (Bt Heart J 1968; 30: 203), click-murmur syndrome, floppy mitral valve. What is the prevalence in the normal population ? The exact prevalence is not known but is between 2 and 10% of the population. It is present in about 7% of females aged between 14 and 30 years (N Engl J Med 1976; 294: 1986). What are the complications of MVP? · Severe mitral regurgitation. · Arrhythmias: ventricular premature contractions, ventricular tachycardia, paroxysmal supraventricular tachycardia. · Atypical chest pain. I · Transient ischaemic attacks (TIAs), embolism. · Infective endocarditis in those with mitral regurgitation. · Sudden death. Mention a few associated conditions. · Marfan's syndrome. · Chronic rheumatic heart disease. · lschaemic heart disease. · Cardiomyopathies. · 20% of patients with atrial septal defects - secundum type. · Ehlers Danlos syndrome. · Psoriatic arthritis. · Ebstein's anomaly. · SLE. How would you manage such patients? · Reassure the asymptomatic patient. · Advise prophylaxis for infective endocarditis in those with the murmur. · Relief of atypical chest pain with analgesics or beta-blockers (empirical treatment). · Aspirin or anticoagulants in those with TIAs. · Antiarrhythmics in those with frequent tachyarrhythmias or ventricular pre-mature contractions. ADVANCED-LEVEL QUESTIONS What is .*he .,'nechanism of the click in MVP? Clicks result from sudden tensing of the mitral valve apparatus as the leaflets prolapse into the left atrium during systole. What are the echocardiographic features of MVP? · M-mode: abrupt posterior displacement of the posterior or sometimes both valve leaflets in mid or late systole. · 2D: systolic displacement of one or both mitral valve leaflets into the left atrium. John Barlow, South African Professor of Cardiology. Celia Oakley, Professor of Cardiology, Hammersmith Hospital, London (Q J Med 1985; 219: 317)