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Healing Hearts and Minds

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Dr. Michael J. Pasquale, medical director of non-invasive cardiac imaging at Christiana Hospital, says people with mitral valve prolapse who show no symptoms should be evaluated every two to three years. Photograph by Christian KayeWhen Michelle Hollingsworth visited Bayhealth Medical Center’s walk-in treatment facility in Dover one weekend a year ago, she was hoping to find relief from a cough that had been nagging her for weeks.

But when the doctor pressed a stethoscope to Hollingsworth’s chest, he discovered something far more troubling than a respiratory infection: With every lub-dub of a normal heartbeat, there came a wooshing sound.

Hollingsworth had learned she had a murmur while a teenager in her native France, but because she’d always been healthy, she dismissed it as harmless.

The Bayhealth doctor told Hollingsworth to see her internist, who referred her to a cardiologist, who sent her for an echocardiogram. A few days later Hollingsworth got the bad news: A complication from a condition known as mitral valve prolapse was allowing an excessive amount of blood to leak into the left atrium of her heart. She would need surgery to repair the valve.

The sudden rush to surgery was a shock to the 63-year-old retiree.

“I had no symptoms,” she says. “That was the scary part.”

Mitral valve prolapse, also known as click-murmur syndrome or Barlow’s syndrome, is a common, usually benign heart problem. About 2 percent of the population has the condition. Women are twice as likely to be affected as men.

The mitral valve is one of four valves in the heart. It opens and closes to create one-way blood flow between the left atrium and left ventricle. The mitral valve has two flaps, or leaflets. In mitral valve prolapse, one or both of the leaflets are too large or the strings that connect them to the ventricular wall are too long. The result is an uneven closure of the valve during each heartbeat. The bad closure causes the valve to bulge, or prolapse, into the left atrium like a parachute, sometimes allowing blood to leak through the valve back into the atrium.

The cause of mitral valve prolapse is unknown, but it appears to be an inherited condition. People with connective tissue disorders such as Marfan syndrome and Ehlers-Danlos syndrome have an increased incidence of mitral valve prolapse, as do those with tall, thin builds, chest-wall deformities or thin chest diameter, and straight-back syndrome.

The disorder is most commonly seen in women between the ages of 20 and 40 but it also occurs in men. Most people who have mitral valve prolapse are surprised to learn they have the abnormality. Those who do experience symptoms typically complain of fatigue, sharp chest pain, irregular heart beats, shortness of breath, dizziness or lightheadedness.

Hollingsworth experienced palpitations when she laid down, but nothing remarkable. Because she’d just lost her husband, she attributed the irregular heartbeats to stress.

But it’s possible that the malfunctioning valve contributed to the persistent respiratory infection she suffered last winter, says Dr. Harjinder S. Grewal, a cardiologist at Kent General Hospital in Dover.

A variety of symptoms led Marcia Tooley to suspect that her valve problem was getting worse. “I was getting pretty tired,” says Tooley, a pediatric physical therapist. “I had leg cramps, and I’d actually wake up at night and feel that I wasn’t breathing.”

Tooley, a breast cancer survivor, learned she had a heart murmur 10 years ago from her oncologist. She remained stable for a few years. Then signs of severe leakage or regurgitation began to appear. Like Hollingsworth, Tooley needed surgery to repair her mitral valve.
 

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Though many cases of mitral valve prolapse are detected during routine physical exams, the problem can be missed, especially if the patient is only examined when lying on his or her back.

“The textbooks describe the click, but not many doctors are able to hear it,” Grewal says. “A lot of doctors don’t even hear the murmur. It all depends on how thorough you are in your examination.”

An echocardiogram is the most useful test for diagnosing mitral valve prolapse, says Dr. Kenneth P. Sunnergren of Cardiology Consultants and Beebe Medical Center in Lewes. Echocardiography uses sound waves to create a moving picture of the heart, providing information about its size and shape and how well the chambers and valves function.

A special type of echocardiogram, a transesophageal echocardiogram, inserts a tube through the esophagus to get a closer look at the mitral valve. Chest X-rays and stress tests are also used to diagnose mitral valve prolapse.

Persons with mitral valve prolapse who are asymptomatic should be reevaluated every two to three years. Those with leaky valves should be monitored annually to make sure the regurgitation is not worsening, says Dr. Michael J. Pasquale, medical director of non-invasive cardiac imaging at the Center for Heart and Vascular Health at Christiana Hospital.

Though most people with mitral valve prolapse never have problems, complications can occur, especially in men over 50, Grewal says.

The most common problem is mitral valve regurgitation, a condition in which the valve is especially leaky. Regurgitation can lead to heart enlargement, heart failure, arrhythmias, and clots that can, in rare cases, cause stroke or lead to sudden death. High blood pressure and being overweight increase the risk of mitral valve regurgitation, Pasquale says.

A poorly functioning valve can also increase the risk of developing endocarditis, an infection of the innermost layer of tissue that lines the chambers of the heart.

Severe mitral valve regurgitation requires surgery to repair or replace the valve to prevent enlargement of the left ventricle, the heart’s main pumping chamber. “Now we are opting for earlier mitral valve surgery because of the good clinical outcomes,” Sunnergren says.

Valve repair rather than replacement is the better option for patients who require surgery, according to the American Heart Association. Surgeons repair the valve by reconnecting the valve leaflets to the heart muscle or by removing excess tissue so the valve can close tightly. Sometimes the ring that connects the valve to the heart muscle is replaced or tightened as well.

Valve replacement is performed when the valve is badly damaged or the patient is in cardiac shock. “Mitral valve repair is a time-consuming operation, so the patients have to be stable,” Sunnergren says.

Both Hollingsworth and Tooley underwent valve repair surgery. Hollingsworth had the procedure in April, Tooley in October 2007. Two months after the surgery, Hollingsworth was pretty much recovered. “I feel good,” she says. ‘I can exercise, I can walk, and I’m not out of breath. I’m glad I had that lung infection. It saved my life.”

Tooley returned to work a couple of months after surgery. Though she feels better, she still suffers from an enlarged heart.

“I can’t do what I used to do, even walking long distances,” she says. “So I gear to what I can do.”

Patients with abnormal rhythms, significant palpitations or chest pains can be treated with medications called beta-blockers, which cause the heart to beat more slowly and less forcefully, thus reducing blood pressure.

Some doctors caution against the use of beta-blockers in women during childbearing years. “Their blood pressure is already on the low side and they’re young and they’re going to get pregnant, so we like to stay away from the medications,” Grewal says.

There are no guidelines for preventing mitral valve prolapse, but maintaining a healthy lifestyle helps to manage symptoms and reduce the risk of complications.

Exercise is encouraged except for those with severe mitral regurgitation. “We try to keep them as active as possible to keep them in good general health, so there’s no restriction on those patients,” Pasquale says. “But those who have a lot of leakiness in the valve should avoid resistance exercises like rowing or weight-lifting.”

Good oral hygiene is also important to prevent bacteria from entering the bloodstream, which can cause endocarditis.

Despite the complications that could occur, most patients with mitral valve prolapse have an excellent prognosis. They usually require no more treatment than a strong dose of reassurance.

“There are many patients who have mitral valve prolapse who are very anxious and they get into panic attacks, they get palpitations, they get shortness of breath,” Pasquale says. “Knowing they have mitral valve prolapse makes them concentrate more on what their heart is doing, so it can feed upon itself. It is more of a psychological barrier to overcome than it is a physiological barrier.”
 

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