Mitral Valve Prolapse

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Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a mid-systolic click and a middle and late systolic murmur loudest in the mitral region, which increased duration with the Valsalva murmur, which I believe is consistent with mitral valve prolapse with presence of mitral regurgitation

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____.

 

On examination of the face, there was no scleral icterus, or conjunctival pallor. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was normal character/small volume (severe) in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat in the was / was not displaced (suggestive a large left ventricle) and was / was not volume loaded (forceful but unsustained). There were/were not any palpable thrills. There was/was not a left parasternal heave or palpable P2, which would suggest pulmonary hypertension.

 

On auscultation, as aforementioned, there was a mid-systolic click with a middle to late systolic murmur loudest in the mitral region. The murmur was longer with dynamic Valsalva (as opposed to MR which is softer) and click earlier, and shorter with squatting and hand grip.

 

There was a normal/soft/absent first heart sound with physiological/fixed/reversed splitting of the second heart sound, with/without an additional third heart sound (severe if present).

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with mitral valve prolapse complicated by mitral regurgitation.  

 

Other differentials include:

• Mitral regurgitation

• Aortic stenosis

• HOCM

• VSD

• Tricuspid regurgitation

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In terms of severity:

• In terms of signs of severity, there was/was not a small volume pulse, a displaced enlarged left ventricle, a third heart sounds, the length of the murmur, an early diastolic rumble, or findings of pulmonary hypertension or left ventricular failure.

 

In terms of the aetiology:

• See list below and comment on if any positive or negative features of this - e.g. In terms of the aetiology, I could not ascertain this with certainty. In terms of of pertinent negatives, there were nil features of connective tissue disease. 

 

I would proceed from here by:

• Confirming my diagnosis with an echocardiogram and assess severity

• I would screen for AF with an ECG, and a CXR for any signs of pulmonary congestion

 

What are the causes?

• Primary - degenerative disease in the absence of identifiable connective tissue disease, sporadic, or familial

• Secondary - Marfan’s, connective tissue disease, PCKD, SLE, IE, papillary muscle rupture

 

What are the associations?

• ASD

• Marfan syndrome

 

What are the complications?

• MR

• IE

 

Which leaflet is affected?

• The murmur of mitral regurgitation with MVP is late-systolic early in the course of the disease, and its point of maximal intensity and radiation pattern varies with the direction of the jet

• With a flail posterior leaflet, the murmur radiates anteriorly and may mimic aortic stenosis, while the murmur associated with a flail anterior leaflet radiates to the back

  • Anteriorly-directed jets can be heard over the entire precordial area, while posteriorly directed jets are typically best heard at the apex and radiate towards the axilla and the back.

• Once a flail or severe prolapse occurs, the murmur becomes holosystolic and is indistinguishable in tone from other causes of mitral regurgitation, but often will remain maximum at mid-late systole.