It’s the most common heart valve condition in the U.S., affecting around 8 million people: mitral valve prolapse. It’s also known as click-murmur syndrome or floppy valve syndrome. What are the symptoms? How serious is it? And how is it diagnosed?
In this episode, Dr. Jonathan Fialkow explores this condition with cardiologist Socrates Kakoulides, M.D., medical director of the ambulatory diagnostic center at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida.
It’s the most common heart valve condition in the U.S., affecting around 8 million people: mitral valve prolapse. It’s also known as click-murmur syndrome or floppy valve syndrome. What are the symptoms? How serious is it? And how is it diagnosed?
In this episode, Dr. Jonathan Fialkow explores this condition with cardiologist Socrates Kakoulides, M.D., medical director of the ambulatory diagnostic center at Miami Cardiac & Vascular Institute, part of Baptist Health South Florida.
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Dr. Jonathan Fialkow:
Hello, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventive cardiologist and lipidologist at the Miami Cardiac & Vascular Institute in Baptist Health South Florida, as well as Chief Population Health Officer at Baptist Health. We started this podcast to answer the kinds of health-related questions my colleagues and I are often asked by our friends and family members. During the last few months, many of these questions have been related to the COVID-19 pandemic, and we've addressed many of these in previous episodes.
Dr. Jonathan Fialkow:
Today we're turning our attention to a condition that affects one of the valves in the heart, the mitral valve. You may have heard of the term mitral valve prolapse before. It's the most common heart valve condition in the United States, affecting about eight million people. What is it? Is it dangerous? How does it affect my life? What should I do if my doctor tells me I have this? Joining me on the podcast today to talk about the causes, symptoms and treatments for mitral valve prolapse and answer these questions is my colleague, Dr. Socrates Kakoulides.
Dr. Jonathan Fialkow:
Dr. Kakoulides is a cardiologist and the medical director of the MCVI Ambulatory Diagnostic Center and an accomplished echocardiographer. Welcome to the podcast, Socrates.
Dr. Socrates Kakoulides:
It's a pleasure to be with you, Jon.
Dr. Jonathan Fialkow:
So Socrates, I asked a couple of questions in the introduction. These are things that we get asked on a regular basis and more. But let's start with a little descriptive term, a little bit of medicine. What is the mitral valve? What does it do as far as normal anatomy and normal function of the heart?
Dr. Socrates Kakoulides:
So, the valves are like doors of the heart. They open and close to let blood pass through the heart. They open to let blood pass between the different chambers and then close to prevent the blood from going back. In mitral valve prolapse, what we have is the valve opens well, but doesn't close well. And as a result, blood goes back through the chambers of the heart.
Dr. Jonathan Fialkow:
So, the mitral valve normally should close and when the heart squeezes, blood should go forward and not back towards the lungs. As you mentioned, the mitral valve prolapse is a situation where the valve doesn't close well, blood goes back to the lungs. That's what you described, correct?
Dr. Socrates Kakoulides:
Exactly. And so-
Dr. Jonathan Fialkow:
So, it's my ... I'm sorry, go ahead.
Dr. Socrates Kakoulides:
And when that blood goes back to the lungs, patients can become symptomatic and feel shortness of breath.
Dr. Jonathan Fialkow:
So, the mitral regurgitation is when the blood goes back. If someone's told they have mitral regurgitation, and we'll talk about how that diagnosis is made shortly, does that mean they have mitral valve prolapse or could other things be causing that?
Dr. Socrates Kakoulides:
Yeah, absolutely. Mitral valve prolapse is one cause of regurgitation, but there are other causes of mitral regurgitation that may not be related to a prolapsing valve. So it's important to get diagnosed properly, to understand the physiology of why you have regurgitation so that you can distinguish, because the therapies that you'll get will be different.
Dr. Jonathan Fialkow:
So again, for the listeners, the mitral valve prolapse, if you will, is a structural problem of the valve that leads to regurgitation. There's lots of other kinds of regurgitation, but it's the regurgitation that causes the problem to the heart. Let's talk a little bit more about regurgitation before we get back to mitral valve prolapse and then the common questions that our listeners may have. What does mitral regurgitation do, and if someone's told "I have regurgitation", what should they be concerned about and what symptoms should they look for to determine if it's something of concern?
Dr. Socrates Kakoulides:
So, when you have mitral regurgitation, as we said, it's when blood, instead of moving forward when the heart beats, it moves back, and it can cause filling and stretching of the chambers of the heart. And so that's diagnosed by echocardiography, primarily, cardiology. And we look at the structure, as we said, the causes of the regurgitation, and then we also try to quantify and determine how much regurgitation there is. We can follow that over time with echocardiography and then also really pay attention to the symptoms that you may be having to determine when it's the right time to intervene.
Dr. Socrates Kakoulides:
So, the symptoms that we're really looking for are decrease in exercise tolerance, so that means you've been able to do certain things and now suddenly you find yourself, you can't climb that flight of stairs that you used to be able to climb or go walk as far as you used to be able to walk. That's the most common finding. Other findings may be an arrhythmia, something called atrial fibrillation, and you'll feel that as palpitations. It may also be felt as shortness of breath. Sometimes in the most extreme cases, you can start to exhibit signs of heart failure. Heart failure will be shortness of breath, even at rest. You may notice some swelling in your legs, a cough. Those are the more extreme findings in the later stages of mitral regurgitation.
Dr. Jonathan Fialkow:
I thank you for those comments. And to our listeners, I wanted to start the conversation by letting you know what the concerns are if you have a significantly prolapsing mitral valve with a severe leak, which would be as Dr. Kakoulides stated, heart failure, shortness of breath with exertion, swelling, arrhythmias. The good news is, that is a vast minority of people with the mitral valve prolapse.
Dr. Jonathan Fialkow:
So, now let's talk about the diagnosis of mitral valve prolapse and where it may become dangerous, but how in most people, it's not a major concern. So, let's talk Socrates, again, in your clinical experience and those of others, what are the kind of findings you see on an echocardiogram that would describe whether mitral valve prolapse ... what have you actually seen with the mitral valve prolapse and how it would help you determine if, "Hey, this is a person who really doesn't have to be concerned" and what that means, or "This is one that we need to follow for the future."
Dr. Socrates Kakoulides:
Yeah. So the kind of things that we're, as you said, we really look at the echo, the ultrasound of the heart, and look at the way that the valve structurally appears. We're looking for any abnormal thickening, lengthening of the leaflets, the way that it moves when it closes, and if it bends back in any particularly abnormal way. And then we use some advanced color features, which allow us to look for regurgitation and see just how much blood there is, that is going back between the chambers of the heart.
Dr. Socrates Kakoulides:
And as you said, with the majority of our patients, the vast majority of our patients with mitral valve prolapse, the regurgitation isn't significant and ... at least initially. And so we follow those patients over time with serial echos, and we can do that depending on how often the cardiologist feels it's necessary to do, and really get a sense of, "Is this valve progressing? Is it getting more? Is it prolapsing worse? Is there worsening regurgitation, or is it stable?" And each patient will be different. And that's why it's very important to have that relationship with the cardiologist, to be able to understand just what kind of prolapse you have and how significant it is and how often it really needs to be followed.
Dr. Jonathan Fialkow:
And again, the level of sophistication you have as a specialist in echocardiography, I think the concern is, which is going to be our next point, is otherwise healthy people might for various reasons have an echocardiogram ordered and a quick interpretation says, "Oh, they have mitral valve prolapse." Rather than the more in depth evaluation that you and others would give on the kind of valve, the structure of the valve, signs that differentiate whether this is something that should be followed long-term, maybe a pathological process versus a kind of normal finding is relevant. So, what would be the kind of more classic description of the person that you may see when you look at an echo or you're asked to review an echo that's been done by someone else, and you say, "Hey, this is really not, it's a prolapsing valve, but it's really not the kind of person or the situation where this person really has to be worried?"
Dr. Socrates Kakoulides:
So, we often find symptoms, the over-diagnosis and I think this of mitral valve prolapse, and where it initially was diagnosed based off of an ultrasound that appeared to be abnormal. And what we found is that as we followed those ultrasounds over time, we really didn't see that prolapse progress in any significant way. We began to understand that this was probably normal physiology and not significant prolapse, and that this was a structurally normal valve. And what that had led to was an over-diagnosis of mitral valve prolapse that clinically would never really manifest and be relevant in a particular patient's life. And a lot of people as a result got ultrasounds that they didn't necessarily need or a diagnosis that never really resulted in anything clinically significant.
Dr. Socrates Kakoulides:
And what we've been trying to do is really understand that physiology and also that structural abnormality that would cause us to say, "Hey, this is a person who's going to potentially have a problem later in life." And that really depends on the structure of that valve. So, we spent a lot of time at our diagnostic center looking and evaluating the mitral valve to make sure that we have that diagnosis correct.
Dr. Jonathan Fialkow:
I love that term you used, over-diagnosis, because it is a real term. And again, for the listeners, the concept of over-diagnosis is someone who gets a test that they didn't really need. The test has a finding that you would be fine if you didn't know you had. So, the context would be a young person, otherwise healthy, maybe has a palpitation, a little concern. The doctor will order an echocardiogram. We could argue if it really is going to be relevant. You get the echocardiogram, you find a little mitral valve prolapse. Now the person is, even though, as the cardiologist with an intense review, you may say, "Hey, this is not a problem. This is not the kind of prolapse that we're concerned about. You don't have a big leak." But now the person is anxious and nervous about carrying this diagnosis with them.
Dr. Jonathan Fialkow:
And it's not without consequence. I mentioned the anxiety component. Let's talk for a little bit about antibiotics. I remember in my day, I'm a little bit older than you, that antibiotics were used routinely for things that we didn't even know if they were necessary, and they're not without consequences. You can get other infections from antibiotics, resistant organisms, side-effects, et cetera. What do we currently do when we find mitral valve prolapse in terms of recommending antibiotics to prevent an infection if you go to the dentist or some other procedure right now?
Dr. Socrates Kakoulides:
Yeah. So, for mitral valve prolapse, we don't recommend antibiotic use for dental procedures. And what we do, we really want to use, as you said, antibiotics in those patients who have significant pathology in which antibiotics will help prevent an infection on that heart valve. Mitral valve prolapse does not rise to the level of concern for us that we would suggest antibiotic use, that the benefit of antibiotics would outweigh the risk.
Dr. Jonathan Fialkow:
Right. People tend to think, "Antibiotics, what's the big deal? I can take it." But yes, there are risks with antibiotics, both to the community with resistant organisms and to the individual. So, I think that's really well said. To this day still, I've had patients who, 20 years ago, they were diagnosed with a mitral valve prolapse by an echocardiogram, which we have confirmed they either don't have anymore or was wrong in the first place, and they still call for antibiotic prescriptions before procedures, and we have to tell them it's not indicated. So, that's [crosstalk 00:12:24]-
Dr. Socrates Kakoulides:
Yeah. If you've had surgery on your heart though, and you've had repair to that valve, then that would be an indication for using antibiotics. So, we do want to use it in the select patients who have had surgical interventions or who have congenital heart abnormalities, but avoid it in those unnecessary cases. Exactly.
Dr. Jonathan Fialkow:
Right. Correct. [inaudible 00:12:46]. What about, again, we talked about it being the most common valve disorder in the United States, any ... What causes it, is it hereditary? Some people just have it? What do we see of [crosstalk 00:13:01] particular causes?
Dr. Socrates Kakoulides:
Yeah. So, from my understanding and my research into this, there's some patients who have a hereditary component to mitral valve prolapse, but for the majority of patients, it's sporadic. There are patients who have, for instance, Marfan syndromes, or Ehlers-Danlos who can develop mitral valve prolapse. But those are the rare patients who have that. So, it is majority of patients who develop mitral valve prolapse, it's sporadic.
Dr. Jonathan Fialkow:
So again, we tend to broaden, we tend to paint with a broad brush, much about prolapse, but the reality is it has to be individualized. If someone is told they have this diagnosis based on an echocardiogram, they can certainly question whether, "It's the kind of finding that I have, but I'm otherwise okay because my valve is structurally all right." Or is it a pathological thing that needs to be followed? And just because you have that diagnosis, far from it means you're going to wind up with a valve replacement or a valve surgery down the road.
Dr. Socrates Kakoulides:
Exactly. And I think what we want to do as much as possible is really understand that cause so that we can tailor our intervention for that particular patient.
Dr. Jonathan Fialkow:
Okay. Last question. You did allude to it, but I do want to challenge the listeners a little bit as well as you. When should someone get an echocardiogram? I know it's very nebulous because it does have to do with a lot of the person's anxiety and the doctor's ability to diagnose and stuff. But from a recommendation standpoint, when would an echocardiogram be worthwhile for someone to evaluate their mitral valve?
Dr. Socrates Kakoulides:
So, when you have symptoms that rise to the level of concern is primarily the reason for getting an ultrasound, an echo. And so the kind of symptoms that we're really looking for are shortness of breath that may be related to a valve disorder. A new murmur that may be associated, may or may not be associated with certain symptoms, and any concern for new, progressive or worsening arrhythmias. Those are the reasons to specifically look for a structural change in the heart that could be diagnosed by ultrasound.
Dr. Jonathan Fialkow:
Fantastic. So again, to the listeners, mitral valve prolapse, a term used frequently, a diagnosis made frequently. Majority of people, it's just a finding on the echocardiogram that was done for their various complaints. Those people that do have the abnormal mitral valve should be followed by certainly a cardiologist, have high quality echocardiograms, like what you and the service that you lead perform. And ultimately, this is a treatable condition for those who need the treatment, which I think is the most reassuring. This is great, Socrates, and I appreciate your time and your expertise. Any final comments or anything you want to reiterate before we close up?
Dr. Socrates Kakoulides:
No, I think this was a really helpful comment. And actually, I think for us as physicians as well to review, this comes up quite often in our patients. They come in with a diagnosis that of mitral valve prolapse, and sometimes I know you've had it and I've had it, we just don't quite know what to make of it. And until we really are able to look at with ultrasounds that valve, can we really determine, "Hey, is this true much without prolapse?"
Dr. Socrates Kakoulides:
And I think we're getting better at really distinguishing those patients who are going to have a problem and those who are not. And I think understanding those patients that are not going to have a problem can lead to fewer tests, fewer interventions, as you said, less anxiety about a diagnosis. And people who are normal can lead a normal life, and we can really focus on that subset, that narrow list that we really need to follow more closely.
Dr. Jonathan Fialkow:
That's great. And I'll add to your comment to say, if someone is diagnosed with mitral valve prolapse, especially without symptoms, it's not an emergency either. It's something that we follow over long periods of time before it may become a problem. So, great stuff. Thank you, listeners. As usual, if you have any ideas, thoughts, topics you'd like to have us do podcasts on the future, please write to us at Baptisthealthtalk@baptisthealth.net. That's Baptisthealthtalk@baptisthealth.net. Stay safe and mask up.
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