Reconsideration of echocardiographic standards for mitral valve prolapse: Lack of association between leaflet displacement isolated to the apical four chamber view and independent echocardiographic evidence of abnormality

Abstract

Mitral valve prolapse by current echocardiographic criteria can be diagnosed with surprising frequency in the general population, even when preselected normal subjects are examined. In most of these individuals, however, prolapse is present in the apical four chamber view and absent in roughly perpendicular long-axis views. Previous studies have shown that systolic annular nonplanarity can cause apparent prolapse in the four chamber view without actual leaflet displacement above the most superior points of the anulus, and there is evidence for such nonplanarity in vivo. It is then reasonable to ask whether superior leaflet displacement limited to the four chamber view has any pathologic significance or complications. The purpose of this study, therefore, was to address the following hypothesis: that patients with superior leaflet displacement confined to the four chamber view have no higher frequency of associated echocardiographic abnormalities than do patients without displacement in any view. Such abnormalities, which would provide independent evidence of mitral valve pathology or dysfunction, include leaflet thickening, left atrial enlargement and mitral regurgitation. Leaflet displacement was measured in the parasternal long-axis and apical four chamber views in 312 patients who were studied retrospectively and selected for the absence of forms of heart disease other than mitral valve prolapse. Leaflet thickness and left atrial size were measured and mitral regurgitation was graded. Patients with leaflet displacement limited to the four chamber view were no more likely to have associated abnormalities than were patients without displacement in any view (0 to 2% prevalence, p greater than 0.5). In contrast, patients with leaflet displacement in the long-axis view were significantly more likely to have associated abnormalities (12 to 24%, p less than 0.005), the frequency of which increased with the extent of leaflet displacement in that view (p less than 0.0001). These results suggest that displacement limited to the apical four chamber view is, in general, a normal geometric finding unassociated with echocardiographic evidence of pathologic significance.

Mitral Valve Prolapse: Current Views and Challenges (Review)

“…Notions about the MVP prevalence remained controversial till the announcement of the results of the community-based Framingham Heart Study [1,39,40], and transition to the unified criteria of ultrasound diagnosis [30] [1,39,40], whose participants were mainly white Americans. Similar results were obtained in the investigations based on Russian population [50].…”

“…Such results were mainly connected with erroneous assumption that a mitral valve has a plane configuration. A series of ultrasound examinations [18,30,31] allowed the physicians to establish that a mitral valve annulus was saddle-shaped, and made the assessment of the valve condition from the parasternal longitudinal position obligatory [32, 33]. Modern medicine defines MVP as a systolic bulging of one or both mitral valve leaflets by no less than 2 mm beyond the mitral annulus plane with its obligatory long-axis registration [5].…”

Prevalence of mitral valve prolapse in primary spontaneous pneumothorax

“…Echocardiographic MVP has been found in 50% of patients with PSP C o p y r ig h t G e n e r a l P r a c t ic e A ir w a y s G r o u p R e p r o d u c t io n p r o h ib it e d [7]. Studies describing the three-dimensional shape of the mitral annulus [8,9] have allowed the two-dimensional (2D-) echocardiographic characterization of the prolapse to be refined, thus minimizing false positive diagnoses [10,11]. We used current 2D-echocardiographic criteria to determine the prevalence of MVP in patients with PSP admitted to Adan teaching hospital in the Ahmadi Governorate in Kuwait.…”

Mitral valve prolapse: where is the missing link?

“…Diagnostically, the debate appeared settled in the 1980's after the seminal description by Levine et al of mitral annulus saddle shape and its influence on MVP diagnosis by echocardiography (1). MVP has since been defined by systolic override of one or both mitral leaflets ≥2 mm above the mitral annulus plane in parasternal long axis or apical 3 chambers view.…”