Patient Presentation
A 17-year-old male came to clinic for his annual examination and sports physical. He ran cross country and track, and had sustained an ankle sprain over the past year which had healed.
The past medical history included mitral valve prolapse which had been noted 2 years previously because of an echocardiogram done as part of a long-QT syndrome evaluation in a maternal aunt. Cardiology had been monitoring him and as he had no symptoms they had cleared him for sports again this year 1 month ago. The family history was negative for any early onset cardiac disease or congenital heart disease. His paternal grandfather had died of a heart attack at age 76 years. The review of systems was negative for any palpitations, syncope or near syncope, and no chest pain. There was no dyspnea or exercise intolerance. He said he only had fatigue after a workout or not sleeping enough.
The pertinent physical exam showed normal vital signs and his height was 75%, and weight was between 25-50%. HEENT was normal. He had no murmur with normal S1, S2 and no clicks. Upper and lower extremity pulses were normal. The rest of his examination was normal.
The diagnosis of a healthy male with asymptomatic mitral valve prolapse was made. The pediatrician reiterated the need to keep well-hydrated, and monitor his body for arrhythmias, chest pain or other symptoms. His next cardiology evaluation was in 11 months.
Discussion
Mitral valve prolapse (MVP) “…is defined as mitral valve displacement more than 2mm above [the] mitral annulus during systole in long axis views” on echocardiogram. MVP is common in the adult population (2-3%, prevalence = 0.6%) occurring often in the middle aged population. It can sporadic or familial. It is associated with connective tissue diseases including Ehler-Danlos syndrome, Marfan syndrome (up to 90% of these patients), osteogenesis imperfecta, and also Grave’s disease and polycystic kidney disease. In children its prevalence is low (0.3%) which suggests that it is a progressive disease. MVP mechanisms causing pathogenesis and progression are not fully understood. Although highly patient specific, the MV leaflets are relatively tethered causing abnormal pressures and blood flow which over time can cause MVP and/or mitral valve regurgitation (MVR). The posterior leaflet is usually more involved than the anterior leaflet or having bivalvular disease. It may be associated with other congenital heart abnormalities.
Clinical presentations include being asymptomatic, but also chest pain, dyspnea on exertion, exercise intolerance and palpitations. Anxiety, mood changes, syncope and fatigue can also occur. Cardiac auscultation findings are of a mid-systolic click with late systolic murmur heard best at the apex, but it can vary. This can be accentuated in standing or Valsalva positions.
MVP is important because of the risk of progression to failure of complete closure and resulting MVR. MVR is relatively rare in children, likely as the anatomic changes of MVP take long periods of time to occur. MVR is treated in adults by no treatment if asymptomatic, beta-blockers if symptomatic and surgery if there is MVR that is severe or progressing. Surgical treatment for children can include repair of the annulus, chordae, leaflet, or combination.
Learning Point
Potential complications of MVP include:
- MVR
- Arrhythmias including atrial fibrillation
- Congestive heart failure
- Sudden cardiac arrest
- Endocarditis
- Stroke
Questions for Further Discussion
1. What are indications for deferment or disqualification from sports participation?
2. What organisms cause infectious endocarditis?
3. What are the most common congenital heart defects?
Related Cases
- Disease: Mitral Valve Prolapse
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: Cardiology / Cardiovascular-Thoracic Surgery
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for this topic: Mitral Valve Prolapse
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
To view videos related to this topic check YouTube Videos.
Cheng Y, Li H, Li G, et al. Surgical Results of Mitral Valve Repair for Mitral Regurgitation in Pediatric Patients with Mitral Valve Prolapse. Pediatr Cardiol. 2022;43(7):1578-1586. doi:10.1007/s00246-022-02885-1
Sabry AF, Reller MD, Evers PD, Madriago EJ. Assessment of the mechanism of mitral valve prolapse in children: An echocardiography study. Echocardiography. 2023;40(7):664-669. doi:10.1111/echo.15631
Shah SN, Gangwani MK, Oliver TI. Mitral Valve Prolapse. In: StatPearls. StatPearls Publishing; 2024. Accessed July 29, 2024. http://www.ncbi.nlm.nih.gov/books/NBK470288/
Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa