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Mitral valve prolapse: diagnosis, treatment and natural course

Regina Jonkaitien, Rimantas Benetis1, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius Clinic of Cardiology, 1Clinic of Cardiac Surgery, Kaunas University of Medicine, Lithuania Key words: mitral valve prolapse, natural course, complications, surgical treatment, mitral valve repair. Summary. This article analyzes data obtained from the medical records of the patients with primary mitral valve prolapse. The study population was the patients admitted to Kaunas University of Medicine Heart Center (KUMHC) between 1999 and 2003. The objective of our study was to analyze the natural course of mitral valve prolapse, complications and their frequency, treatment strategy in KUMHC, as well as to review the results of surgical treatment. We gathered data from the medical records of 160 patients and analyzed their age, medical history, complications, comorbidities, functional status and echocardiographic parameters. Patients who underwent mitral valve surgery were followed 7.98.4 months after procedure. On average, 3214 patients with primary mitral valve prolapse were treated at KUMHC annually. Their mean age was 48.416.5 years, 44.4% of them were male. The most frequent complications of mitral valve prolapse were II mitral regurgitation (78.4%), various cardiac arrhythmias (68.1%) and heart failure of II NYHA class (79%). Surgical treatment was recommended for 64 (40%) KUMHC patients with primary mitral valve prolapse. Surgical treatment was applied in 44 (28.1%) of study patients. The patients, who were recommended surgical treatment, were older (mean age 53.211.9 years, p<0.05) and predominantly male (62.5%, p<0.05) as compared to medically managed patients. The heart failure (62.5% had NYHA class III or IV), severe mitral regurgitation (95.3% had mitral regurgitation of III) and worse left ventricle function (15% had ejection fraction of <50%) were more frequent in this group as compared to medically managed patients (all p<0.05). During the last five years the number of hospitalized patients with primary mitral valve prolapse increased 3.2 times, the number of mitral valve surgical procedures among these patients increased 2.8 times, and the number of mitral valve repair increased 15.8 times. 56.8% of patients had uncomplicated postoperative course. The most frequent postoperative complication was new arrhythmias and/or conduction disturbances. 1 patient died in early postoperative period. There was significant decrease in left ventricle and left atrium size and the severity of mitral regurgitation 2 to 6 months after mitral valve surgery. These positive changes remained during all study period. Taking in the consideration the large number of mitral valve repair procedures and good outcomes, the low postoperative mortality of the surgical mitral valve prolapse treatment in KUMHC, we can strongly recommend surgical treatment for the patients with severe mitral regurgitation secondary to mitral valve prolapse. Introduction Mitral valve prolapse (MVP) is an abnormal movement of one or both mitral valve leaflets (morphologically normal-appearing, or redundant and thickened) into the left atrium during systole (Fig. 1). Synonyms for MVP include Barlow syndrome or disease, billowing mitral valve, floppy mitral valve, myxomatous mitral valve, systolic/mitral clickmurmur syndrome. MVP can be primary or secondary. Primary MVP appears in otherwise healthy heart and is associated with genetic factors. Secondary MVP can develop in the patients with coronary heart disease, rheumatic heart disease, etc. (1). Mitral valve prolapse was first described in 1966 by Barlow and Bosman (2). Since then medical literature offers variable and often controversial data about MVP epidemiology, natural course, complications, diagnostics and treatment strategies. Mitral valve prolapse is quite heterogenous disease according to its natural course. Populational stu-

Correspondence to R. Ablonskyt-Dudonien, Clinic of Cardiology, Kaunas University of Medicine, Eiveni 2, 50009 Kaunas, Lithuania. E-mail: rutmin@kaunas.init.lt

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Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

Fig. 1. Normal mitral valve (A) and posterior leaflet prolapse (B) AL anterior leaflet of mitral valve; PL posterior leaflet; PA pulmonary artery; Ao aorta. dies show that more than one half of the patients with MPV are asymptomatic and usually have benign course of the disease. Their overall morbidity and mortality is similar to general population (3). However, in the remaining portion of cases MVP may be associated with severe cardiovascular complications, such as progressive mitral regurgitation, arrhythmias, heart failure, increased risk of infective endocarditis and 7.8% of the patients with MVP require mitral valve surgery (3). Different authors from various centers had provided variable data concerning MVP course, complications and their frequency (37). Any clinical or epidemiological studies on MVP have not been conducted in Lithuania so far, hence the MVP clinical course, treatment strategy and results, own surgical treatment experience have not been analyzed. There are no generally accepted criteria for the optimal timing of mitral valve surgery in MVP. Indications for the MPV surgical treatment in Kaunas University of Medicine Heart center (KUMHC) were outlined following ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (published in 1998 (1)) and ESC Working Group Recommendations on the Management of the Asymptomatic Patient with Valvular Heart Disease (published in 2002 (8)). These guidelines are based upon extensive worldwide experience and the results of the mitral regurgitation surgical treatment. However, majority of the studies on which the guidelines are based have not separated patients with mitral valve prolapse. Moreover, majority of the specialists (9, 10) note that indications for the surgical treatment of mitral valve prolapse as well as the timing of the surgery should be based upon the experience and the results in particular hospital. Therefore, analysis of surgical experience in our medical center is important. The objective of this study was to analyze the natural course of mitral valve prolapse, its complications and their frequency, the management strategy, as well as experience and results of the surgical treatment at KUMHC. Patients and methods The records of a total of 160 subjects (mean age 48.416.5 years, 44.4% male) with primary MVP hospitalized in KUMHC from 1999 to 2003 were analyzed. The diagnosis of MVP was made by the physical examination (midsystolic or telesystolic click with a systolic murmur on the heart auscultation) and two-dimensional echocardiography. Two-dimensional echocardiography was performed in all patients. Then transesophageal two-dimensional echocardiography was performed in 31.2% of study patients to confirm the diagnosis. Echocardiographic diagnosis of MVP was made using Freed et al. criteria (6). Patients with the secondary MVP due to coronary heart disease or rheumatic heart disease were excluded. Associated incidental coronary artery disease was not an exclusion criterion. In the medical records of patients with primary MVP we looked at the age, past medical history,
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Mitral valve prolapse: diagnosis, treatment and natural course comorbidities, complications of mitral valve prolapse, as well as patients functional state according to New York Heart Association (NYHA) classification, and echocardiographic measurements (such as end-diastolic left ventricle dimension (EDLVD), left atrium diameter (LA), left ventricle ejection fraction (EF) by Simpsons method, the degree of mitral regurgitation). We also evaluated the change of two-dimensional echocardiographic findings over five years in operatively managed patients. Patients who underwent mitral valve surgery were followed up in average for 7.98.4 months (from 2 to 39 months) after procedure. Statistical analysis was performed using STATISTICA 5.0 software. Quantitative values were mean and standard deviation. The comparison of data from groups of recommended either medical management or surgical, as well as the group of operated patients versus those who refused surgery was performed using Students t-test for the independent samples. Comparison between two-dimensional echocardiographic findings before and after surgery was made using Students t-test for dependent samples. The difference between two variables was considered statistically significant if p value was equal or less than 0.05. All p tests were two-sided. Results Data analysis shows that between 1999 and 2003, 3214 patients with primary mitral valve prolapse were hospitalized annually in KUMHC. Surgical treatment was recommended to 64 (40%) patients. Surgery was performed in 45 (28.1%) of all MPV patients treated in KUMHC during study period, which 70 Percent (from patients with MVP hospitalized during particular year) 60 50 40 30 20 10 0 0 0

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was annually 96.4 of these patients. 19 (29.7%) of all patients who were referred for an operative treatment refused surgery. The rate of the hospitalizations due to MVP increased 3.2 times (7.5% to 23.7%) in 5-year period since 1999. And the number of patients who were referred for the heart surgery increased 3.3 times (from 16.7% to 55.3%). The number of patients who underwent surgery was 2.8 times bigger in 2003 than in 1999 (Fig. 2). The study population was divided into 4 groups: patients to whom medical management was recommended, patients to whom surgical management was recommended, the group of patients who underwent surgery, and the group of patients who refused surgery. The summary of the clinical characteristics of these 4 groups is shown in Table 1. All study patients were further divided into two groups according to their NYHA functional status (NYHA III and NYHA IIIIV) and into four groups according to the degree of mitral regurgitation. In order to estimate the rate of progression of mitral regurgitation and heart failure in MVP patients, the mean age was calculated and compared in all subgroups mentioned above. 103 (64.4%) patients were assigned to NYHA III group, their mean age was 42.014.8 years; respectively 57 (35.6%) patients were assigned to NYHA IIIIV group, mean age 59.813.1 years (p<0.0001). Mitral regurgitation of I was diagnosed to 32 (20.9%) patients, their mean age was 55.113.1 years; II mitral regurgitation 44 (28.7%) patients,

20 20

Percent (from hospitalized (from Percent hospitalized patients with MVP)

40 40

Surgery recommended (primary axis) Underwent surgery (primary axis) Rejected surgery (primary axis) Hospitalized with MVP (secondary axis)

-20 -40 -60 1999 2000 2001 2002 2003

Year Fig. 2. Management strategy variation in patients with mitral valve prolapse during 19992003
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patients with MVP)

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Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius Table 1. Clinical characteristics of the patients with primary mitral valve prolapse
Total n=160 (%) Medical management group n=96 (%) 31 (32.3) 65 (67.7) 43.917.7 Group of patients referred for surgical treatment n=64 (%) Surgical treatment group n=44** (%) 27 (61.4) 17 (38.6) 53.211.9 19 (43.2) 25 (56.8) 20 (45.4) 9 (20.4) 0 0 1 (2.3) 1 (2.3) 7 (15.9) 2 (4.5) 8 (18.2) 6 (13.6) 0 16 (36.4) 22 (50.0) 6 (13.6) 21 (52.5){l} 14 (35.0){l} 5 (12.5){l} 0{l} 0 0 1 (2.3) 16 (36.4) 27 (61.4) 14 (31.2) 12 (27.3) 18 (40.9) Group of patients who rejected surgery n=19 (%) 12 (63.1) 7 (36.8) 54.77.1

Features

Male Female Age (mean SD)

71 (44.4) 89 (55.6) 48.416.5

40 (62.5) 0.0002* 24 (37.5) 0.0002* 55.111.8 <0.0001* 0.06 0.59 0.05* 0.42 0.70 0.03* 0.23 0.60 0.20 0.18 0.001* 0.02* <0.0001* 0.03* <0.0001* 0.01* 0.14 0.008* 0.02*

0.88 0.88 0.61

Medical history: Hypertension 63 (39.9){a} 32 (33.7){b} 31 (49.2){c} Arrhythmias (any) 109 (68.1) 67 (69.8) 42 (65.6) AF/AU 58 (36.2) 29 (30.2) 29 (45.3) PVB 49 (30.6) 32 (33.3) 17 (26.6) PVT 4 (2.5) 3 (3.1) 1 (1.6) PSVT 13 (8.1) 13 (13.5) 0 Heart block/pacemaker 7 (4.4) 6 (6.25) 1 (1.6) Marfan syndrome 2 (1.2) 1 (1.0) 1 (1.6) Coronary artery disease 21 (13.1) 10 (10.4) 11 (17.2) Aortic valve disease 6 (3.7) 2 (2.1) 4 (6.2) Infect. endocarditis (total) 12 (7.5) 2 (2.1) 10 (15.6) Active endocarditis 9 (5.6) 2 (2.1) 7 (10.9) NYHA functional class 1 2 3 4 LV ejection fraction 60% 5059% 4049% <40% Degree of mitral regurgitation none 1 2 3 4 Affected leaflet Posterior Anterior Both 32 (20.0) 71 (44.4) 50 (31.2) 7 (4.4) 32 (33.3) 49 (51.0) 14 (14.6) 1 (1.0) 0 22 (34.4) 36 (56.2) 6 (9.4)

11 (61.1){k} 0.20 17 (89.5) 0.01* 9 (47.4) 0.88 8 (42.1) 0.07 1 (5.3) 0.14 0 0 0.54 0 0.54 5 (26.3) 0.36 2 (10.5) 0.39 2 (10.5) 0.49 1 (5.3) 0.30 0 8 (42.1) 11 (57.9) 0 5 (26.3) 11 (57.9) 3 (15.8) 0 0 0 1 (5.3) 12 (63.1) 6 (31.6) 5 (26.3) 8 (42.1) 6 (31.6)

0.65 0.56 0.09 0.06 0.10 0.76

51 (36.4){d} 25 (31.2){e} 26 (43.3){f} 77 (55.0){d} 52 (65.0){e} 25 (41.7){f} 12 (8.6){d} 3 (3.7){e} 9 (15.0){f} 0{d} 0{e} 0{f} 1 (0.6){g} 1 (1.1){h} 32 (20.9){g} 32 (35.9){h} 44 (28.7){g} 41 (46.1){h} 40 (26.1){g} 12 (13.5){h} 36 (23.5){g} 3 (3.4){h} 29 (19.9){i} 10 (12.2){j} 76 (52.0){i} 55 (67.1){j} 41 (28.1){i} 17 (20.7){j} 0 0 3 (4.7) 28 (43.7) 33 (51.6) 19 (29.7) 21 (32.8) 24 (37.5)

0.42 <0.0001* <0.0001* 0.0001* <0.0001* 0.008* 0.0001* 0.02*

0.52 0.05* 0.04* 0.69 0.24 0.50

n number of the patients; p level of statistical significance; AF/AU atrial fibrillation or undulation; PVB premature ventricular beats; PVT paroxysmal ventricular tachycardia; PSVT paroxysmal supraventricular tachycardia; NYHA New York Heart Association classification; LV left ventricle; {a} n = 158; {b} n = 95; {c} n = 63; {d} n = 140; {e} n = 80; {f} n = 60; {g} n = 153; {h} n = 89; {i} n = 146; {j} n = 82; {k} n = 18; {l} n = 40; * statistically significant difference between comparable groups; ** one patient had postoperative diagnosis other than mitral prolapse, so he was not included into further analysis.

mean age 47.217.0 years (comparing I and II mitral regurgitation groups p=0.03), III mitral regurgitation 40 (26.1%) patients, mean age 33.611.6 years (comparing II and III mitral regurgitation groups p=0.0001), IV mitral regurgitation 36 (23.5%) patients, mean age 57.213.5 years (comparing III and IV mitral regurgitation groups p<0.0001).

Operative data of the patients with primary MVP are shown in Table 2. Table 3 shows data about the early postoperative period. Analysis of annually performed heart operations revealed that number of mitral valve repair surgeries was increasing, and from 1999 to 2003 increased by 41.6% (from 2.8% to 44.4%) (Fig. 3).
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Mitral valve prolapse: diagnosis, treatment and natural course Table 2. Operative data of the patients with mitral valve prolapse Features Number of surgery Mitral anuloplasty Tricuspid valve repair Other operation in conjunction Coronary artery bypass Aortic valve replacement Reoperation n number of patients. Total, n (%) 44 27 (61.4) 15 (34.1) 8 (18.2) 4 (9.1) 4 (9.1) 1 (2.3)

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Table 3. Incidences during early postoperative period Incidences Uncomplicated Complicated: Death New arrhythmias / conduction disturbances Cardiogenic shock Resternotomy due to bleeding Sepsis Pneumothorax Total, n (%)* 27 (61.4) 17 (38.6) 1 (2.3) 9 (20.4) 1 (2.3) 2 (4.5) 3 (6.8) 1 (2.3)

n number of patients; * total number of surgery patients was 44.

Percent

50 40
30.5

44.4

30 20 10 0 1999 2000 2001 2002 2003

8.3 2.8

13.9

Years

Fig. 3. Changes of the relative number of mitral valve repairs Analysis of two-dimensional echocardiography measurements up to 40 months after surgery revealed that EDLVD significantly decreased over 26 months after surgery (8.83.7 mm, p<0.0001). The same trend was found with LA dimensions (long dimension decreased by 6.83.5 mm, p=0.0002; short dimension by 4.45.9 mm, p=0.04)). Left ventricular EF also decreased but remained normal. The greatest change was noticed 2 to 6 months after surgery (8.55.1%, p=0.0005, or from 56.07.6%. to 51.2 5.3%). Later left ventricular EF did not change significantly. 40 months after surgery mean EF was 50.0%. Figure 4 shows dynamics of two-dimensional
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echocardiography measurements after surgery. Change of the mitral regurgitation severity after surgery is reflected in Figure 5. Discussion This retrospective study analyzed data of the patients with MVP who already had cardiac symptoms severe enough to be admitted to the hospital. Therefore, study population is not random and reflects only the group of patients with primary MVP who were symptomatic. Consequently, these patients were likely to have much higher incidence of complications, as well as requirement for surgical treatment compared

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Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

80 100 100

LA dimension, EDLVD (mm)

70 60 50 40 30 20

90 90 80 80
EF (perc.) EF (perc.)
Long dimension of LA Short dimension of LA EDLVD EF

70 70 60 60 50 50
40

1 26 712 Months after sugery

1340

Fig. 4. Postoperative changes of two-dimensional echocardiographic measurements 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 0.5

MR degree

1
-1

26 712 2-6 7-12 Months after sugery

1340
13-40

Fig. 5. Postoperative change of the degree of mitral regurgitation to the rest of the patients with MVP. Recent worldwide populational studies showed that the prevalence of MVP in general population was rather low: 0.62.4% (6, 11). The hospitalization rate, the need for surgical treatment and the number of mitral valve surgeries due to MVP are growing every year, despite low MVP prevalence. They increased near 3 times over the past 5 years. This can be attributed to the improvement in the technique of cardiac surgery in KUMHC. The frequency of the surgical mitral valve repair is increasing every year. Moreover, the opinion of the cardiologists about surgical treatment of MVP has changed, and because of the new clinical research (9) mitral valve surgery is more frequently recommended for asymptomatic and minimally symptomatic patients with severe mitral regurgitation. These patients are more likely to have better long-term survival than symptomatic patients (NYHA functional class III or IV). In our study the mean age of patients with primary MVP was 48.4 years. Etiology of primary MVP is associated with the genetic factors (1214). The natural course of the disease is rather benign. Symptoms and complications usually appear only after 40 or 50 years of age. The patients to whom surgical treatment was recommended were significantly older than the
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Mitral valve prolapse: diagnosis, treatment and natural course patients in medical management group (mean age 55.1 vs. 43.9 years, respectively; p<0.0001). It means that even when complications appear approximately 10 years pass till surgery is required. Symptomatic MVP was equally distributed between both sexes, but the need for heart surgery due to complications of MVP was bigger in males (62.5% of patients to whom heart surgery was recommended were males). In comparison, only 32.3% were males in medical management group (p=0.0002). These results correspond to the ones of the other researchers (15, 16) who had also observed that the patients older than 45, the males and those with the severe mitral regurgitation had a higher risk for MVP complications. The most frequent complication of mitral valve prolapse is the progression of mitral regurgitation (3). It causes dilatation and dysfunction of left atrium and left ventricle, cardiac arrhythmias, and later heart failure, increased risk of infective endocarditis. Second degree or more severe mitral regurgitation was found in 78.4% of the patients. Common complication of MVP was cardiac arrhythmias. They were diagnosed in 68.1% of the patients. The most frequent types of cardiac arrhythmias were: atrial fibrillation (36.2%) and premature ventricular complexes (30.6%). Another common complication was a heart failure. NYHA functional class III or IV was found in 35.0%. 44.0% of the patients had NYHA functional class II. Infective endocarditis was more prevalent in MVP patients than in the general population. The prevalence of infective endocarditis in general population of Lithuania is 0.004% (17). 7.5% of study patients had infective endocarditis at some point of their lives. 5.6% had endocarditis during study period (active endocarditis). Two patients (1.2%) who had past history of MVP, needed mitral valve replacement surgery during study period due to complications of the infective endocarditis of mitral valve. Other MVP complications were quite rare. 4.4% of the patients due to disturbances of the heart conduction required pacemaker placement. 2.5% of the patients had thromboembolic events. Arterial hypertension as comorbidity was found in 39.9% of patients and commonly it was mild. Comparison of the mean age of study patients according to their NYHA functional status revealed that the patients who had NYHA functional class III were significantly younger than the patients who had NYHA functional class IIIIV (mean age 42.0 vs. 59.8 years, respectively; p<0.0001). We can premise that in case of complicated MVP the heart failure progress usually is rather slow. First heart failure symptoms usually appear only after 40 or 50 years of age. Approximately
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15 more years passes until heart failure symptoms become severe. We did not find consistency that the severity of mitral regurgitation would increase with age while analyzing the mean age of study patients according to the degree of their mitral regurgitation. The mean age of the patients with mitral regurgitation of I and IV was similar (55.1 vs. 57.2 years, respectively). It can be concluded that progress of heart failure was not always associated with the increasing mitral regurgitation. Other MVP complications (e.g. arrhythmias or conduction disturbances) as well as comorbidities, especially hypertensive cardiopathy and coronary heart disease also played a significant role in the development of heart failure. Anterior leaflet prolapse was diagnosed in 52% of the study patients, bileaflet prolapse in 28.1%, and posterior leaflet prolapse in 19.9%. Therefore, anterior leaflet prolapse was 2.6 times more prevalent than posterior leaflet and 1.8 times more prevalent than bileaflet prolapse. Posterior leaflet and bileaflet prolapse were significantly more prevalent in the group of patients to whom surgical treatment was recommended as compared to medical management group (29.7% vs 12.2%, p=0.008 and 37.5% vs. 20.7%, p=0.02; respectively). Anterior leaflet prolapse was less prevalent in the surgical treatment group (32.8% vs. 67.1% in medical management group; p=0.0001). It is described in the medical literature that in primary MVP posterior leaflet is affected more frequently (9, 10). The lesion of anterior leaflet is characteristic of rheumatic heart disease (1). It is not clear why anterior leaflet prolapse was more prevalent than posterior leaflet prolapse in our study patients. Possible explanation could be that due to saddle-shaped configuration of the mitral valve, as it was shown with three-dimensional echocardiography (18), prolapselike picture could be seen in certain two-dimensional echo cardiographic views, and it can be mistaken for mitral prolapse (false positive results). More precise diagnostic method, transesophageal two-dimensional echocardiography was more frequently used in the surgical treatment group than in medical management group (50.8% vs. 18.7%, respectively; p<0.0001). Therefore, false positive results are less likely in the surgical treatment group. Current guidelines for indications for the surgical treatment in mitral regurgitation and for the optimal timing of corrective surgery are recommended considering the presence or absence of symptoms, EF, EDLVD, LA enlargement, the presence of pulmonary hypertension. Patients to whom surgical treatment was recommended had worse EF, more severe mitral regurgita-

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Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius gery group patients. One patient died on the third day after mitral valve repair. His postoperative course was complicated by cardiogenic shock, progressive heart failure. Consequently, the early postoperative (30 day) mortality after mitral valve surgery in KUMHC was 2.3% during study period, so it was similar to other centers 0.3% (19), 1.02% (9), 2.6% (20). Risk factors for increased cardiovascular mortality in patients with MVP were found to be mitral regurgitation of II, EF<50% (3, 19). Predictors of higher cardiovascular morbidity are mitral regurgitation, LA40 mm, atrial fibrillation, patients age 50 years (3, 19). We have reviewed the postoperative change of twodimensional echocardiography measurements such as the degree of mitral regurgitation, EF, LA diameter, EDLVD. The mean degree of mitral regurgitation prior to the surgery in the surgical treatment group was 3.6 0.5. It decreased to 0.860.9 right after surgery (p< 0.0001). As shown in Figure 5 during the late postoperative period the mean degree of mitral regurgitation in the surgical treatment group was increasing slightly but did not exceed 1.20.4 and remained significantly lower than before the surgery during all study period. In various publications it has been noted that EF increased after surgery (9, 10, 20). Analysis of our results revealed that left ventricular EF slightly decreased after surgery but still remained normal. The peak mean difference of 8.55.1% (from 56.07.6% to 51.25.3%; p=0.0005) was observed 2 to 6 months after surgery. Left ventricular EF did not change significantly later, and 40 months after surgery mean EF was 50.0%. EDLVD significantly decreased 2 to 6 months after surgery (8.83.7 mm; p<0.0001) and LA dimensions did as well (long dimension 6.83.5, p=0.0002; short dimension 4.45.9, p=0.04). Mean EDLVD in the surgical treatment group remained normal all study period, and 13 to 40 months after surgery was 44.50.7 mm. LA mean short dimension in the surgical treatment group decreased to normal over 2 to 6 months after surgery and remained the same all study period (13 to 40 months after surgery was 42.50.7 mm). At the same time long dimension of LA did not return back to the normal even though it decreased by 9.35.4 mm (p=0.008) 7 to 12 months after surgery. Looking at these results we can state that the remodeling of the left ventricle and the left atrium occurred 2 to 6 months after surgery and remained stable during all study period, i.e. up to 40 postoperative months. Almost one third of the patients who were referred for the surgical treatment rejected surgery. The comMedicina (Kaunas) 2005; 41(4)

tion, and were more symptomatic than the patients in medical management group. EF less than 50% was found in 15% of the first group patients vs. 3.7% of patients in the second group (p=0.02). Mitral regurgitation of III or worse was prevalent 95.3% and 16.8% respectively (p=0.0001). NYHA functional class III or IV was found significantly more prevalent in the group of patients who were recommended surgical treatment than in medical management group (62.5 vs. 16.7%; p<0.0001). 43.3% of the patients who were referred for the surgical treatment and 52.5% of the patients who underwent surgery had EF60%, i. e. those patients underwent surgery with normal left ventricular function. 41.7% and 35.0% of the patients in before mentioned groups, respectively, had EF 50 60%. These patients underwent surgery with slightly impaired left ventricular function. Only 15.0% of the patients that were referred for the surgical treatment and 12.5% of the patients that agreed to it had EF <50%. These patients underwent surgery with poor left ventricular function, so the surgery was overdue. The age, NYHA functional class, the measurements of two-dimensional echocardiography of the surgically treated patients, the timing of the mitral valve surgery as well as the surgical methods in KUMHC are the same as in developed centers worldwide (9, 10). Both worldwide and in KUMHC mitral valve surgery has been performed more frequently in the symptomatic patients. 63.6% of the subjects in our surgery group had NYHA functional class III or IV. In the latest publications one can find more and more data about superior long-term results of the mitral valve surgery in asymptomatic and minimally symptomatic patients. More symptomatic patients have bigger chance of worse long-term results and shorter longterm survival than asymptomatic and minimally symptomatic patients. During the last five years the number of mitral valve repairs is growing steadily and has increased 15.8 times. Mitral valve repair was combined with mitral anuloplasty in 61.4% of the patients. Mitral valve surgery was combined with tricuspid valve repair in more than 30% of patients. It was done at the same time as coronary artery bypass surgery in 9.1% of the patients. And it was done with aortic valve replacement in 9.1% of the patients. 61.4% of the patients had uncomplicated postoperative course. The most frequent postoperative complications were new cardiac arrhythmias and/or conduction disturbances (20.4%). Other complications (cardiogenic shock, resternotomy due to major bleeding, pneumothorax) were documented in 9.1% of the sur-

Mitral valve prolapse: diagnosis, treatment and natural course parison of clinical characteristics between the groups of the patients who underwent surgery and those who resigned it revealed that both groups had the same demographic data (sex, age) as well as similar comorbidities. Though III mitral regurgitation was more prevalent in the group that rejected surgery (63.1 vs. 36.4%; p=0.05), both groups had the same NYHA functional class and EF. Therefore, we can conclude that the reasons to reject surgery were subjective and dependent on persons fear of surgery itself as well as its complications. This fear in turn is caused by the lack of information about natural course of this disease, treatment options and good results of the surgical treatment. Conclusions 1. Though symptomatic primary mitral valve prolapse is not a common disease the hospitalization rate and number of heart surgeries due to mitral valve prolapse is growing steadily every year.

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2. The most common causes of the hospitalization in MVP patients were: development of mitral regurgitation, severe mitral insufficiency, cardiac arrhythmias and heart failure. More than one third of patients with mitral valve prolapse required heart surgery. 3. Number of mitral valve repairs is growing steadily in KUMHC every year. 4. The remodeling of the left ventricle and the left atrium occurred during six months after mitral valve surgery. At that time the echocardiography measurements of left heart were decreasing, mitral regurgitation was not increasing and these positive changes remained during all study period (40 months). 5. Taking in the consideration the large number of mitral valve repair procedures and good outcomes, the low postoperative mortality, as well as regression of the left heart dilatation after surgery, we can strongly recommend surgical treatment in KUMHC for the patients with severe mitral regurgitation secondary to mitral valve prolapse.

Mitralinio votuvo prolapso diagnostikos, gydymo ir eigos ypatybs

Regina Jonkaitien, Rimantas Benetis1, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius Kauno medicinos universiteto Kardiologijos klinika, 1Kardiochirurgijos klinika Raktaodiai: mitralinio votuvo prolapsas, eigos ypatybs, komplikacijos, chirurginis gydymas, mitralinio votuvo plastika. Santrauka. Straipsnyje nagrinjami duomenys apie 19992003 metais Kauno medicinos universiteto klinik irdies centre dl pirminio mitralinio votuvo prolapso gydyt pacient skaii, j klinikines charakteristikas, chirurgin gydym. Darbo tikslas. Ianalizuoti pirminio mitralinio votuvo prolapso eigos ypatybes, komplikacijas bei j dan, Kauno medicinos universiteto klinik irdies centre taikom gydymo taktik, chirurginio gydymo rezultatus bei patirt. Ianalizuota 160 pacient medicinin dokumentacija: vertintas tiriamj amius, anamnez, komplikacijos ir gretutins ligos, funkcin bkl, echokardiografiniai rodmenys. Operuot ligoni echokardiografini rodmen dinamika stebta 7,98,4 mnesio po mitralinio votuvo korekcijos operacijos. Kauno medicinos universiteto klinik irdies centre kasmet gydyta 3214 pacient, kuriems diagnozuotas pirminis mitralinio votuvo prolapsas, j amius 48,416,5 met, 44,4 proc. i ligoni vyrai. Daniausios mitralinio votuvo prolapso komplikacijos buvo II arba didesnio laipsnio mitralinio votuvo nesandarumas (78,4 proc.), vairs irdies ritmo sutrikimai (68,1 proc.), II arba didesnio laipsnio NYHA funkcins klass irdies nepakankamumas (79 proc.). Chirurginis gydymas rekomenduotas 64 (40 proc.) Kauno medicinos universiteto klinik irdies centre gydytiems pacientams, kuriems diagnozuotas pirminis mitralinio votuvo prolapsas. Operuoti 44 (28,1 proc.) tiriamieji. Lyginant su konservatyvaus gydymo grupe, didesn dal pacient, kuriems rekomenduotas chirurginis gydymas, sudar vyrai (62,5 proc.). ie pacientai buvo vyresni (amiaus vidurkis 55,111,8 met), jiems buvo rykesni irdies nepakankamumo simptomai (62,5 proc. IIIIV NYHA funkcins klass), didesnio laipsnio mitralin regurgitacija (95,3 proc. regurgitacija buvo III ir didesnio laipsnio) ir blogesn kairiojo skilvelio funkcija (15 proc. nustatyta istmimo frakcija maiau nei 50 proc.) (vis mint rodmen skirtumo tarp grupi p<0,05). Per pastaruosius penkerius metus dl mitralinio votuvo prolapso hospitalizuot pacient skaiius padidjo 3,2 karto, operacij skaiius iems pacientams 2,8 karto,
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Regina Jonkaitien, Rimantas Benetis, Rta Ablonskyt-Ddonien, Renaldas Jurkeviius

mitralinio votuvo plastik skaiius 15,8 karto. Pooperacin eiga 56,8 proc. pacient buvo sklandi. Daniausia pooperacin komplikacija nauji irdies ritmo ir laidumo sutrikimai. Ankstyvuoju pooperaciniu laikotarpiu mir vienas pacientas. Per 26 mnesius po mitralinio votuvo operacijos ymiai sumajo kairiojo skilvelio ir kairiojo prieirdio matmenys bei mitralins regurgitacijos laipsnis ir ie teigiami pakitimai iliko vis stebjimo laikotarp. vertinus ma pooperacin mirtamum, chirurginio gydymo efektyvum, mitralinio votuvo plastik santykin dan ir pooperacin kairiosios irdies dilatacijos regresavim, chirurgin gydym Kauno medicinos universiteto klinik irdies centre galima pagrstai rekomenduoti pirminiu mitralinio votuvo prolapsu sergantiems pacientams, nustaius didesnio laipnio mitralin regurgitacij.
Adresas susirainti: R. Ablonskyt-Ddonien, KMUK Kardiologijos klinika, Eiveni 2, 50009 Kaunas El. patas: rutmin@kaunas.init.lt

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Received 29 December 2004, accepted 12 April 2005 Straipsnis gautas 2004 12 29, priimtas 2005 04 12

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