Murmur Of Mitral Regurgitation Research Articles

Prognostic significance of mitral regurgitation in acute myocardial infarction

To define the frequency, natural history and clinical correlates of the murmur of mitral regurgitation (MR) detected after myocardial infarction, clinical data from 849 patients with documented acute myocardial infarction were analyzed. A murmur suggestive of MR was present on admission in 76 patients (9%). Patients with MR on admission were older and more apt to be female and nonwhite. They also had a significantly greater frequency of prior infarction and signs and symptoms of congestive heart failure. There was no difference in the location (anterior or inferior) of infarction. Patients with MR on admission had a 36% mortality compared to 16% for those who developed MR later in the hospitalization and 15% for those without MR by auscultation (p < 0.001). Correction for diferences in baseline variables indicated that the presence of MR on admission did not contribute independently to mortality. Thus, the murmur of MR derives its prognostic significance from integration of multiple clinical, radiographic and electrocardiographic characteristics.

Bedside diagnosis of systolic murmurs.

The diagnostic accuracy of bedside maneuvers in the evaluation of patients with systolic murmurs has not been assessed objectively. Therefore, we evaluated 50 patients with documented systolic murmurs and compared all standard bedside techniques. Murmurs originating within the right-sided chambers of the heart were best differentiated from all other murmurs by augmentation of their intensity with inspiration (100 percent sensitivity, 88 percent specificity) and diminution of their intensity with expiration (100 percent sensitivity, 88 percent specificity). The murmur of hypertrophic cardiomyopathy was distinguished from all other murmurs by an increase in intensity with the Valsalva maneuver (65 percent sensitivity, 96 percent specificity) and during squatting-to-standing action (95 percent sensitivity, 84 percent specificity), and by a decrease in intensity during standing-to-squatting action (95 percent sensitivity, 85 percent specificity), passive leg elevation (85 percent sensitivity, 91 percent specificity), and handgrip (85 percent sensitivity, 75 percent specificity). The murmurs of mitral regurgitation and ventricular septal defect had parallel responses to all maneuvers, but could be differentiated from other systolic murmurs by augmentation of their intensity with handgrip (68 percent sensitivity, 92 percent specificity) and during transient arterial occlusion (78 percent sensitivity, 100 percent specificity), and by a decrease in their intensity during the inhalation of amyl nitrite (80 percent sensitivity, 90 percent specificity). No single maneuver identified the murmur of aortic stenosis, but the diagnosis could be made by exclusion. Although no single maneuver is 100 percent accurate in diagnosing the cause of a systolic murmur, its origin can be determined accurately at the bedside by observation of the response to a combination of maneuvers.

Reassessment of echocardiographic criteria for diagnosis of mitral valve prolapse

Commonly used echocardiographic criteria for mitral valve prolapse (MVP) include a sizable proportion of persons whose hearts are normal. Nevertheless, the echocardiogram is generally used as an independent standard for the diagnosis of MVP despite lack of consensus on the criteria to be used and the probability of interobserver variability. Conversely, there is a relatively uniform consensus that classic auscultatory signs establish the diagnosis of MVP beyond reasonable doubt. Accordingly, in 148 patients referred for evaluation of known or suspected MVP, the echocardiographic patterns that coincide with diagnostic auscultatory signs were studied prospectively to compare those patterns with criteria commonly used for the echocardiographic diagnosis of MVP and to determine interobserver variability in echocardiographic interpretation. Eighty patients (54%) had a classic mid- to late systolic click or an apical late systolic murmur, or both. Eleven patients (7%) had the apical holosystolic murmur of mitral regurgitation with no discemible clinical or echocardiographic cause other than the consideration of MVP. Doppler echocardiography was performed in 80 of the 148 patients. The degree of superior systolic bowing of each mitral leaflet and the location of leaflet coaptation relative to the presumed plane of the mitral anulus were graded on apical 4-chamber and parastemal long-axis views. The only patterns absolutely specific for auscultatory MVP were: severe bowing of the anterior or posterior leaflet; coaptation of leaflets on the left atrial side of the anular plane; moderate to severe Doppler mitral regurgitation accompanied by any degree of leaflet bowing; and mild Doppler mitral regurgitation accompanied by moderate bowing of a leaflet. These echocardiographic patterns were relatively insensitive in predicting auscultatory MVP, but reliance on them avoids the misdiagnosis of MVP in normal hearts.

Correlation of prevalence and severity of mitral regurgitation and mitral stenosis determined by Doppler echocardiography with physical signs of mitral regurgitation and mitral stenosis in 100 patients aged 62 to 100 years with mitral anular calcium

Apical systolic murmurs of mitral regurgitation (MR) were heard in 129 of our 293 unselected elderly patients (44%) with mitral anular calcium (MAC). 1 Apical diastolic murmurs of mitral stenosis (MS) were heard in 28 of our 293 elderly patients (10%) with MAC. 1 We performed a blinded prospective study to determine the prevalence and severity of MR and MS determined by technically adequate pulsed and continuous-wave Doppler recordings in elderly persons with MAC correlated with physical signs of MR and MS.

Primary myocardial disease (cardiomyopathies): a study of 69 cases.

The clinical features, hemodynamic data and follow up of 69 children with cardiomyopathy (CM), up to the age of 12 years has been detailed. The diagnosis of CM was based on the report of WHO task force. Of the 69 children dilated CM was found in 64 cases whereas restrictive and hypertrophic cardiomyopathy were present in two and three patients respectively. The patients with dilated CM presented with congestive failure late in the course of the disease. Twenty-four of the 64 patients were found to have a mitral regurgitation murmur. The electrocardiogram was abnormal in each case; the common abnormalities being left or biventricular hypertrophy with nonspecific ST and T changes. Hemodynamic studies showed elevated right and left ventricular enddiastolic pressures and increased left ventricular volumes. In spite of clinical congestive failure right atrial pressure can be normal in infants with CM. Follow up was possible in 26 patients of whom 16 showed recovery. Of the 16 patients who showed recovery 10 have recovered completely (asymptomatic with normal heart size). The clinical, electrocardiographic radiological and hemodynamic data of patients who have recovered did not differ from those who did not show improvement. Vigorous anticongestive measures combined with bed rest was the main stay of treatment. The number of patients with restrictive and hypertrophic CM was too small for meaningful conclusions.

Correlation of murmurs of mitral stenosis and mitral regurgitation with presence or absence of mitral anular calcium in persons older than 62 years in a long-term health care facility

Correlation of murmurs of mitral stenosis and mitral regurgitation with presence or absence of mitral anular calcium in persons older than 62 years in a long-term health care facility

Syndromes de Marfan ou marfanoïdes : intérêt de l'échocardiographie

The purpose of this study of 6 cases of Marfan's or Marfan-like syndrome detected in 7077 echocardiographic examinations was to investigate the clinical value of echocardiography. The mean age of the patients was 40 years, and 4 of them (66 p. 100) were female. The diagnosis was based on the 4 criteria of Marfan's syndrome in 1 case, on 3 criteria in 2 cases and on 2 criteria in 3 cases. Four patients were known to have a previous cardiac murmur. Auscultation revealed a systolic murmur of mitral regurgitation in 3 cases (associated with a diastolic murmur of aortic regurgitation in 2 of them), a diastolic murmur of aortic regurgitation in 3 cases and a systolic murmur due to calcified bicuspid aortic valve in 1 case. ECG recorded a normal rhythm in 4 cases, atrial fibrillation in 2 cases of mitral regurgitation, and left ventricular hypertrophy in 3 cases. Chest X-ray showed cardiomegaly in 3 patients and severe kyphoscoliosis in one. Echocardiography visualized dilatation of the ascending aorta, severe (60 mm) in 1 case, in 3 patients; dilatation of the pulmonary artery in 1 patient; pansystolic mitral valve prolapse in 3 patients (associated with aortic and tricuspid valve prolapse in 2 of them after the disease had progressed); isolated aortic valve prolapse due to bicuspid valve in 2 patients; intracardiac calcifications in 3 patients; subaortic septal hypertrophy in 1 patient and calcified incompetent foramen ovale in 1 patient. Aortography performed in 3 patients disclosed an aneurysm of Valsalva's sinuses in 1 case and a mild aortic insufficiency in 2 cases. Two patients underwent cardiac catheterization for severe mitral regurgitation due to mitral valve prolapse requiring valve replacement, which was successfully done. Thus, echocardiography may provide an early diagnosis of Marfan's syndrome, since cardiovascular abnormalities are frequent in infancy. It also ensures a close follow-up of the disorders and it is useful in deciding whether treatment should be medical or surgical. It may detect formes frustes in a family with Marfan's syndrome, and it may define a borderline group of patients: those with Marfan-like syndrome. In these patients the cardiovascular lesions are more preponderant and appear later than in the classical Marfan's syndrome; they are often difficult to differentiate from the lesions of Barlow's syndrome.

Complications of mitral valve prolapse: Disproportionate occurrence in men and older patients

To determine factors influencing the strength of association between mitral valve prolapse and mitral regurgitation, ruptured chordae tendineae, and infective endocarditis, the prevalence of mitral prolapse in patients with disease was compared with both clinical and population control groups. The prevalence of mitral valve prolapse was 4 percent among population and clinical control groups (eight of 196 and 84 of 2,146, respectively) and was significantly higher (p <0.001) in patients with endocarditis (11 of 67, 16 percent), mitral regurgitation (17 of 31, 55 percent, and ruptured chordae (27 of 43, 63 percent). Odds ratios for complications in persons with mitral valve prolapse ranged from 4.6 for endocarditis to 41.4 for ruptured chordae in overall analyses, and from 6.8 for endocarditis to 53.0 for ruptured chordae based on age- and sex-matched case-control triplets (p <0.001 for each). All complications occurred disproportionately in men with mitral valve prolapse, in whom odds ratios ranged from 2.5 to 7.4 compared with an additional control group of unselected subjects with mitral valve prolapse. Compared with this control group, patients with mitral valve prolapse and endocarditis were slightly more likely to have a previously known heart murmur (odds ratio 3.2, difference not significant) but significantly more likely to have murmurs at the time of evaluation (odds ratio 8.5, p <0.01). Patients with mitral valve prolapse and mitral regurgitation and ruptured chordae tendineae were also significantly older than the unselected subjects with mitral valve prolapse (48 ± 14 and 55 ± 16 versus 38 ± 14 years, p <0.005 for both). The concentration of risk of endocarditis in men with mitral valve prolapse and patients with antecedent murmur suggests that antibiotic prophylaxis is warranted in these groups but not in women without a murmur of mitral regurgitation.

Phonoechocardiography and intracardiac phonocardiography in hypertrophic cardiomyopathy.

The salient phonoechocardiographic features of patients having hypertrophic cardiomyopathy (HCM) with or without left ventricular outflow tract (LVOT) gradients are reviewed. Intracardiac sound and pressure recordings from high fidelity catheter-tipped micromanometers have documented that the precordial murmur is the summation of both the systolic ejection murmur (SEM) arising from the LVOT, as well as the mitral regurgitant murmur recorded from the left atrium. The intensity of the precordial murmur varies directly with the LVOT gradient, which in turn is determined primarily by the contractility and loading conditions of the left ventricle. Reversed splitting of the second heart sound (S2) with paradoxical respiratory movement is a common finding in HCM, and when present, almost always denotes a significant LVOT gradient. It is due to marked lengthening of the left ventricular ejection time secondary to prolongation of the contraction and relaxation phases of left ventricular systole. The presence of a fourth heart sound (S4) is the rule in HCM when normal sinus rhythm is present, and is a reflection of a forceful left atrial contraction into a hypertrophied noncompliant left ventricle. A third heart sound (S3) is also common in HCM, and often the initial vibrations occur before the 0 point of the apexcardiogram (ACG) and continue giving the auscultatory impression of a diastolic rumble. When associated with a loud S1, which is frequently present, the clinical presentation may mimic mitral stenosis. This is particularly true when the patient has chronic atrial fibrillation. Careful attention to evidence of marked left ventricular hypertrophy as well as the typical echocardiographic findings of HCM preclude this diagnosis. In conclusion, phonoechocardiography is a simple non-invasive technique which almost always makes the definitive diagnosis of HCM.

Systolic fluttering of the noncoronary cusp of the aortic valve and the posterior wall of the aortic root--a sign of mitral regurgitation due to dysfunction of the posterior leaflet of the mitral valve.

ABSTRACTTen consecutive patients with severe isolated mitral regurgitation were studied. All the patients were evaluated by physical examination, EKG, chest X‐ray, M‐mode echocardiogram, and left ventricular angiogram. In eight patients a systolic murmur of mitral regurgitation radiated to the left parasternal and aortic areas. All of these patients demonstrated fluttering of the noncoronary cusp of the aortic valve and the posterior wall of the aortic root.Two patients in whom the systolic murmur of mitral regurgitation did not radiate to left parasternal and aortic areas, did not show fluttering of the noncoronary cusp and the posterior aortic wall. These patients had a classical murmur of mitral regurgitation that radiated to the left axilla.A review of 120 normal echocardiograms revealed fluttering of the right coronary cusp in three cases. None of these echocardiograms demonstrated fluttering of the noncoronary cusp or the posterior wall of aorta.The findings lead us to conclude that the presence of systolic fluttering of the noncoronary cusp and the posterior wall of the aorta is suggestive of mitral regurgitation due to dysfunction of the posterior leaflet of the mitral valve. Isolated fluttering of the right coronary cusp is a nonspecific finding.

Ruptured papillary muscle, a complication of myocardial infarction: clinical presentation, diagnosis, and treatment.

Ruptured papillary muscle due to myocardial infarction was encountered in 14 patients during the period 1975-1983. Five of the 14 patients had a history of angina pectoris and two had a history of prior myocardial infarction. Eleven patients with myocardial infarction developed additional pain due to myocardial ischemia and/or a murmur of mitral regurgitation and pulmonary edema within a week, 3 others had a prolonged course with intermittent pain due to myocardial ischemia and breathlessness for longer periods and then deteriorated. Thirteen of our 14 patients developed a murmur and all but one had pulmonary edema on the chest x-ray. Five patients had infarction patterns on the electrocardiogram, the remainder of the patients had only ST- and T-wave changes. Echocardiograms showed fine flutter and notching of the anterior mitral leaflets and vigorous contractions of the left ventricle. Only one patient was demonstrated to have a papillary muscle tip prolapsing into the left atrium on two-dimensional echocardiography. Twelve patients underwent surgery and 8 survived. Seven patients had single-vessel coronary disease, 4 involving the circumflex system and 3 involving the right coronary system. Four of the 7 patients with single-vessel coronary disease survived surgery. Five patients went to surgery with the intra-aortic balloon pump in place and only 3 survived. Three others had the pump inserted intraoperatively and 2 of these survived. Six of 9 patients who had mitral valve replacement and coronary bypass survived. Ejection fraction ranged from 40 to 79%. Surgical survival did seem to be related to the extent of papillary muscle rupture, with the best results occurring in the group with a small portion of the tip ruptured. Seven patients had a stormy clinical course and required surgery within 10 days of rupture. Four of these 7 survived. It seems reasonable to believe that these patients who often have small infarction and limited coronary disease have good potential for survival. Our approach has been to move toward surgery once the diagnosis is made to avoid the sudden deterioration that frequently occurs. The surgical mortality in this group remains in the 30 to 40% range.

Relationship between auscultatory events and structural abnormalities in mitral valve prolapse: A two-dimensional echocardiographic evaluation

The purpose of this study was to examine the relationship between the valvular abnormalities and auscultatory findings of patients with mitral valve prolapse (MVP). Forty patients with typical auscultatory and two-dimensional echocardiographic (2DE) findings were studied. Eleven of 14 patients with anterior leaflet MVP (group I) had mid to late systolic clicks without murmurs of mitral regurgitation, while eight of nine patients with posterior leaflet prolapse (group II) and 13 of 17 patients with combined anterior and posterior prolapse (group III) had murmurs of mitral regurgitation. In each subgroup the mitral anulus size was greater than a control group (group I = 3.8 ± 0.1 cm, p < 0.025; group II = 3.9 ± 0.1 cm, p < 0.005; group III = 4.2 ± 0.2 cm, p < 0.001; and control = 3.4 ± 0.1 cm), but the largest anulus was present in patients with combined prolapse. As demonstrated by 2DE, prolapse of a single mitral leaflet may occur in many instances of MVP. Murmurs of mitral regurgitation occur frequently when the posterior mitral leaflet alone prolapses, while isolated clicks are found with anterior mitral leaflet prolapse.

Idiopathic restrictive cardiomyopathy.

This report details the clinical, hemodynamic, and morphologic data from four patients 59 to 77 years old (mean 66) with a primary restrictive cardiomyopathy. All patients had symptoms of congestive heart failure, jugular venous distention, and murmurs of mitral and tricuspid regurgitation. Four patients required pacemakers, three for the brady-tachy syndrome and one for complete heart block. Chest x-ray demonstrated cardiomegaly in all four patients and pulmonary congestion and/or pleural effusions in three. Echocardiographic examination documented left atrial enlargement in all patients, along with normal left ventricular internal dimensions. Global left ventricular systolic function was normal in all, and left and right ventricular filling pressures were elevated and similar in three. A dip and plateau pattern was present in the pressure tracings of two of three patients. Unlike previous reports of restrictive cardiomyopathy, in our four patients there was no specific morphologic cause noted at necropsy. Pathologic evaluation demonstrated biatrial dilatation in all patients, with thrombi present in the atrial appendages in three. Normal ventricular cavity size and mild right ventricular hypertrophy were present in all patients and mild-to-moderate left ventricular hypertrophy was present in two. There were no significant pericardial, endocardial, or valvular abnormalities and no infiltrative myocardial disorders were present. Light and electron microscopic studies demonstrated only interstitial fibrosis of the myocardium. A restrictive hemodynamic profile may be observed in the absence of specific infiltrative disorders and affected patients may exhibit a prolonged clinical course of 4 to 14 years (mean 9). However, in these patients congestive heart failure responded poorly to medical therapy or surgical correction of valvular regurgitation, which is common in this disorder.

Acute thrombosis of Sorin tilting disc mitral prostheses

We observed four cases of prosthetic thrombosis in 77 patients who had had a tilting disc valve (Sorin model) inserted in the mitral position. In all cases, the clinical findings on admission consisted of congestive heart failure, absence of prosthetic closing click and mitral regurgitation murmur. M-mode and cross-sectional echocardiography were invariably diagnostic. Surgery was performed without delay and consisted of thrombectomy in one case and valve replacement with porcine xenograft in three. Examination of the explanted prostheses disclosed fibrous tissue overgrowth surrounding the valvular ring, as well as thrombotic vegetations on the ventricular and atrial sides. The disc appeared blocked in a semiopening position at an angle of 45°. Our experience suggests that the thrombosis is secondary to disc malfunction itself produced by periannular tissue growth. It is related to the porosity of the fabric which surrounds the metal ring, the valve design and its orientation. Correct anticoagulation therapy, performed in all cases, had no significant effect on tissue overgrowth. The high postoperative mortality rate depended on the severity of the preoperative clinical condition of the patients.

Mitral valve dysfunction in the Marfan syndrome: Clinical and echocardiographic study of prevalence and natural history

Although mitral regurgitation and fibromyxomatous thickening of the mitral leaflets have long been recognized as such, mitral valve prolapse has only recently been added as one of the pleiotropic features of the Marfan syndrome, the prevalence, age of onset, and natural history of mitral valve dysfunction in this condition are uncertain. Therefore, all patients in one clinic who met strict diagnostic criteria for the Marfan syndrome and who had clinical and echocardiographic examinations before age 22 years were reviewed. Of the 166 patients (84 males, aged 11.9 ± 0.6 years [mean ± SEM]; and 82 females, 11.0 ± 0.6 years), 52 percent had auscultatory and 68 percent had echocardiographic evidence of mitral valve dysfunction, generally mitral valve prolapse. Prevalence did not differ between the sexes. Follow-up in 115 patients averaged five examinations over a mean of four years; 17 percent were followed for more than six years. Criteria for progression of mitral valve dysfunction were: (1) on auscultation, the appearance of new systolic clicks or apical systolic murmurs, a mitral regurgitant murmur increased by two grades, or appearance of congestive heart failure not due to aortic regurgitation; and (2) on echocardiography, the new appearance of mitral valve prolapse or abnormally increased left atrial dimension. Nearly half the patients met at least one criterion and one quarter had both auscultatory and echocardiographic evidence of progressive mitral valve dysfunction. Twice as many females demonstrated worse mitral valve function with time. Eight of the 166 patients either died as a result of mitral valve dysfunction or required mitral valve replacement. Severe mitral regurgitation developed in an additional 15 patients. Rupture of chordae tendineae was uncommon. Antibiotic prophylaxis was routine, and no cases of bacterial endocarditis of the mitral valve occurred. These results suggest that mitral valve dysfunction is extremely common in young patients with Marfan syndrome and usually presents as mitral valve prolapse. Serious mitral regurgitation develops in one of every eight patients by the third decade. Thus, the prevalence and natural history of mitral valve prolapse in the Marfan syndrome appear distinct from mitral valve prolapse associated with other conditions, including idiopathic or familial mitral valve prolapse.

A controlled evaluation of the risk of bacterial endocarditis in persons with mitral-valve prolapse.

The absence of controlled evidence and the high prevalence of mitral-valve prolapse have created substantial uncertainty about whether this condition is an important risk factor for bacterial endocarditis. We evaluated this risk in a case-control study of hospital inpatients who had undergone echocardiography and who lacked any known cardiovascular risk factors for endocarditis, apart from mitral-valve prolapse and isolated mitral-regurgitant murmurs. Thirteen (25 per cent) of 51 patients with endocarditis had mitral-valve prolapse, as compared with 10 (seven per cent) of the 153 matched controls without endocarditis. For the 51 matched case-control sets, the odds ratio (8.2; 95 per cent confidence interval, 2.4 to 28.4) indicated a substantially higher risk of endocarditis for people with mitral-valve prolapse than for those without it. This association remained statistically significant when parenteral drug abuse and routine antibiotic prophylaxis preceding dental work and other forms of instrumentation were taken into account. Furthermore, the risk may be higher than is indicated by this study, since 46 per cent of the controls underwent echocardiography for clinically suspected mitral-valve prolapse, suggesting an overrepresentation of mitral prolapse in the control group. The results support the contention that mitral-valve prolapse is a significant risk factor for bacterial endocarditis.

Mechanism of a musical systolic murmur caused by a degenerated porcine bioprosthetic valve

The cause of a musical (cooing) murmur produced by a degenerated bioprosthetic valve in the mitral position was investigated. Spectral analysis of the murmur recorded at the chest wall at the site of the maximum palpable impulse showed virtually all sound in a narrow frequency band around the dominant frequency of 158 hertz. The same valve, surgically removed and mounted in the mitral position in a pulse duplicating system, produced an audible musical murmur detected by a phonocatheter in the atrial chamber. Nearly all of the sound-pressure occurred in a narrow band of frequency around 145 hertz. High speed motion pictures (500 frames/s) showed systolic flutter of a flail leaflet. The frequency of this leaflet flutter was 142 hertz. Hot film anemometry showed minimal turbulence, all located near the margin of the regurgitant leaflet. The intensity of the murmur was unrelated to the intensity of turbulence. A second degenerated bioprosthetic valve that produced in vivo a typical blowing holosystolic mitral regurgitant murmur produced in vitro a murmur with a broad range of frequencies (20 to 500 hertz). With this valve, the intensity of the murmur was related to the intensity of the turbulence. Motion pictures showed no leaflet flutter. Flutter of an insufficient valve leaflet causing uniform and periodic high frequency fluctuating pressures therefore appeared to be the cause of the musical quality of the systolic murmur in a degenerated bioprosthetic valve.

Echocardiographic visualization of the anatomic causes of mitral regurgitation resulting from myocardial infarction.

Summary A murmur of mitral regurgitation in patients with congestive heart failure after an acute myocardial infarction suggests a surgically correctable cause of the heart failure. Six patients who presented in this manner and who later underwent surgery have been evaluated by two-dimensional echocardiography (2DE). The underlying anatomical cause of the mitral regurgitation was correctly identified as papillary muscle rupture (2 cases), ruptured chordae tendineae (1 case) and papillary muscle fibrosis (3 cases). Two-dimensional echocardiography is useful in evaluating patients with congestive heart failure who develop a systolic murmur after acute infarction, as it can detect surgically correctable structural defects.

Idiopathic mitral valve prolapse-analysis by real-time two-dimensional echocardiography.

Mitral valve prolapse is diagnosed in real-time two-dimensional echocardiograms when there are discrepancies in the coaptation zone of the anterior mitral leaflet and the posterior mitral leaflet. Out of the 100 cases of mitral valve prolapse diagnosed in this way, 65 had prolapsed anterior mitral leaflets, 28 prolapsed posterior mitral leaflets and 7 prolapses of both the anterior and posterior mitral leaflets. In addition to the cases with mitral valve prolapse 23 cases of ruptured chordae tendineae of the mitral valve, including 15 cases which had undergone surgery, were investigated. The frequent site of mitral valve prolapse was the posteromedial commissure in the anterior leaflet and the posteromedial and anterolateral commissures in the posterior leaflet. These sites coincide with those where rupture of the chordae tendineae of the mitral valve was apt to occur. An investigation of the relation between age and mitral valve prolapse showed that the number of cases of prolapsed anterior leaflet did not increase with age, but there was an age-related increase in the number of cases of prolapsed posterior leaflets. It was also found that the degree of the prolapse progressed with age. Many of the cases of ruptured chordae tendineae of the mitral valve were in their forties or fifties, and there appeared to be some relation between the progress of the prolapse and age. Mitral regurgitant murmurs were recorded on phonocardiograms, and the severer the degree, the wider the range of the prolapse. Mitral regurgitation was more likely to occur in cases of prolapsed posterior leaflets than in those with prolapsed anterior leaflets, even if the degree and the range of the prolapse were mild.

An angiographic assessment of left ventricular function in isolated mitral valvular prolapse.

Angiographic studies demonstrating alterations in left ventricular contraction have been cited as evidence that isolated mitral valve prolapse (MVP) may be associated with a cardiomyopathy. We studied 17 patients with isolated MVP undergoing cardiac catheterization who had chest pain, palpitations, and/or a murmur of mitral regurgitation. Eleven of 13 patients (85%) with no or mild (Grade 1+) mitral regurgitation had normal left ventricular hemodynamic measurements, while three of four patients (75%) with moderate or marked (Grades 2+-4+) regurgitation had abnormal left ventricular hemodynamic measurements. An increased mean rate of circumferential fiber shortening (greater than 1.9 circumferences/sec) was observed in nine of 13 patients (70%). Systolic ventricular wall motion was analyzed from left ventriculograms by methods which quantitate percent shortening of ventricular areas, transverse chords, and radial axes. Marked variations in the number and location of alterations in ventricular contraction were obtained by the different methods used to analyze the ventriculograms, with segments of hypokinesis being detected in from 0-14 patients studied, depending upon the method used. Localization of alterations in contraction predominantly in the basal and mid-segments of the left ventricular and the association of hemodynamic abnormalities with mitral regurgitation suggest that changes in ventricular contraction are primarily related to an alteration of mitral valve function in this condition.