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Forum Name: Cardiology Symptoms

Question: Has MVP been missed on echocardiogram???


 Rainbow1 - Wed Nov 12, 2008 9:26 am

I'm a 35 year old tall slim female with many of the typical MVP symptoms. I suffered stress depression and anxiety from childhood, and took antidepressants for many years (dosulepin). I had Cognitive Behavioural Therapy which has virtually cured me, and after reducing them gradually, stopped them totally in April this year. Two months after this I started getting heart symptoms including: chest pain, severe palpitations, a choking sensation, dizziness, and near faints.
I had a 4 day heart monitor which showed extra beats, and these are my echo results:
LV appears undilated with normal wall thickness. Overall/reasonable/good systolic LV function with an estimated EF55%. In the apical views the IVS appears mildy dyskinetic.
RV appears undilated with good contractility.
RA/LA of normal size.
All valves appear structurally normal for age. Unable to determine number of cusps for AV.
Trivial mitral regurgitation detected using doppler.
MMode/2d measurements & calculations
IVSd: 0.80 cm
LVIDd: 4.1 cm
LVIDs: 2.7 cm
LVPWd: 0.70 cm
FS: 34%
ESV(Teich): 27 ml
EF(Teich) 64%
LA dimension: 2.6 cm
When I had a guided tour of my heart, I saw the 2 chamber apical view, and was shown my left venticle, atrium & mitral valve. The leaflet that I could see was an arced horseshoe shape, and as it was beating it seemed to be wavering.
Does this all sound normal, as I've been told I definitely haven't got MVP? I would really appreciate some advise on this matter. Thank you.
 John Kenyon, CNA - Thu Nov 20, 2008 10:43 pm

User avatar Hi there -

Your perplexity is understandable, and yes, one might say MVP could be "missed" on echo. Actually what sometimes happens is that it disappears. It's difficult to find two doctors who will agree on the diagnostic criteria for MVP anyway, as many prefer to regard it as a "variant of normal." What you describe re: the visible mitral leaflet is that it may possess "redundant" tissue, which is a roundabout way of saying it's not perfectly normal, but doesn't meet a given doctor's "gold standard" for prolapse. (The actual gold standard is a triad which is rarely seen: floppy leaflet, click murmur and flattening of T-waves in some leads).

In short, one may have MVP and/or MVP syndrome without prolapse being revealved upon echocardiogram. Then the patient must either accept the (questionable) diagnosis of no MVP, or seek a second opinion.

MVP, when it is treated, is almost always treated symptomatically, and some centers regard the syndrome as the condition, not the other way around. Therefore, some people, those with significant and disruptive or disturbing (to the patient) symptoms are treated for the symptoms, usually with a beta blocker, which reduces both the frequency and force of premature beats, discourages paroxysmal tachycardia from occurring, and helps with chest pain and other symptoms. Some patients are also given an anti-anxiety medication as well, if that seems appropriate, since anxiety and panic attacks, as you already know, are frequently associated with MVP or at least the syndrome.

Since the mitral leaflets are composed of vascular tissue, they can shrink and enlarge just enough to appear "redundant", prolapsed or normal on any given day of any give echocardiogram. Because of this it can be "missed" or, more properly, be missing, at any given time and yet appear some other time. The syndrome is what is important, as the valvular derangement is almost never significant and doesn't even account for the symptoms anyway.

You certainly describe the symptoms which comprise MVP syndrome, even though you may not have a concrete diagnosis of MVP and, in fact, have been told the opposite. Well, you didn't have it that day. But the syndrome, because it doesn't necessarily correlate with the prolapse anyway, is what is treated, and what you probably have. It's not life threatening, not dangerous, but can be very frustrating, alarming, and lifestyle-threatening (causing one to limit one's activity needlessly).

You might consider a second opinion for this, since while your heart is structurally normal, with or without MVP, you may well benefit from medical treatment of MVP syndrome.

I hope this is helpful. You're healthy, but if you don't feel as though you are, it's understandable. Best of luck to you, and please follow up with us as needed.
 Rainbow1 - Fri Nov 21, 2008 4:43 pm

Thank you so much for your reply, you're the first medical professional to take me seriously, and to take the time to help me to understand what is going on with me, and I really appreciate it.
I've decided to take your advise and ask for a second opinion, and will let you know how I get on.
One last thing, on my echo report it said 'In the apical views the IVS appears mildy dyskinetic' what does that mean?
Thank you once again.
 John Kenyon, CNA - Fri Nov 21, 2008 11:31 pm

User avatar You're very welcome!

I think the second opinion is a pretty good idea, even if it doesn't yield any new information.

About that "mildly dyskenetic IVS": the IVS is your intraventricular septum, the wall which separates the two lower chambers of the heart so the fresh and "used" blood doesn't mix. "Mildly dyskenetic" means it moves a tiny bit sluggishly relative to the free walls of the ventricles. This is usually a pretty meaningless finding, but we are obligated to note all things normal and, consequently, anything that isn't exactly as described in the textbook. It's more a description than a diagnosis of anything, and this particular finding borders on being completely meaningless.

Again, you're very welcome. Every patient deserves to be taken seriously, but you fall into a subset of patients who often are not, which is something of a sore spot with me. It's my pleasure to take the time to explain these things. I hope you'll follow up with us after your second opinion, and follow up with us if you have any further questions as well.
 Rainbow1 - Sat Nov 22, 2008 6:42 am

Thank you very much for explaining that to me, and I will definitely let you know what happens with my second opinion - might be some time as the National Health Service can be a bit slow over here!
 John Kenyon, CNA - Sat Nov 22, 2008 12:59 pm

User avatar You're very welcome. I'll be waiting. :)
 Rainbow1 - Fri Mar 27, 2009 8:19 pm

Hi,
At last I've managed to get a second opinion, but it's not been an easy task though!
I started off by talking about it with my Doctor, and was told that I was ok. I then ended up being taken to Accident & Emergency, they gave me an ECG which lasted about 30 seconds, and they sent me home after telling me it was normal.
I then decided that I'd had enough of the NHS, and decided to ask my Doctor for a private referral to see a Cardiologist, which she was happy to do.
I was lucky as the half an hour appointment that I had, was with the lead consultant in the area, and he took the time to listen, and explain things to me.
He looked at my reports and said that there is a possibilty that I have got MVP, but as the regurgitation is only slight at present, it is of no significance. He asked if I had a history of Marfans in the family (which I haven't) as apparently I have the typical build of people affected by this syndrome. He also said that females; particularly ones with my build, are more likely to get mitral regurgitation, and has suggested that I contact him on a yearly basis to have an Echocardiogram, to check whether or not it has worsened.
When I asked about medication for my symptoms, he said that they would normally prescribe a betablocker, but in my case he did not think it would be a good idea, as my blood pressure is quite low, and it may make me feel worse.
Even though I still frequently suffer the symptoms, I do feel reassured that I'm not about to drop dead. Although, I do feel a bit disappointed that I didn't have a second Echocardiogram, and the chance of possibly having MVP diagnosed, so I still don't really have a definite answer to what causes my symptoms.
What do you think, should I just accept this, and hope it shows up in my echocardiogram next year?
Thank you
 John Kenyon, CNA - Sat Mar 28, 2009 11:37 am

User avatar Good deal about the private referral! That worked out extremely well, it seems.

I think you got a comprehensive and useful answer, and the sort that you may want to get used to, since marginal MVP is often not visible and is clincally inconsequential. What's important is the set of symptoms that is associated with it, even when it's not actually possible to visualize the MVP. The only real use of an MVP diagnosis is that more doctors are more likely then to treat the symptoms, even though they have no clear conncection to the prolapse anyway. This is an enduring mystery, why people with even borderline or intermittent finding of MVP (or none at all) can have significant, annoying (though not dangerous) symptoms. It's worth going back to check on a yearly basis, and perhaps one of those times it will be evident. The important thing, though, is that the symptoms be treated, since the actual prolapse, if there is any, is almost always irrelevant to anything else.

It's true, or at least seems to be the case (I'm not sure anyone has actually compiled statistics) that tall, willowy people with longer than average long bones (arms, legs) and who tend to look similar to possible Marfan's patients, do tend to have MVP more often, as well as loose joints, and other Marfan's-like issues, without actually having the genetic defect and actual Marfan's syndrome. Also, women seem more likely than men, in general, and women of your build in particular, to have either MVP or at least MVP sydrome. Again, what's important is to relieve the symptoms or at least help the patient adapt to them. In some clinics, at least here in the US, MVP syndrome without a finding of MVP is called dysautonomia, meaning a malfunction or inappropriate responses by the autonomic nervous system, which is what MVP syndrome is anyway. The symptoms are classic, and are often treatable with beta blocking drugs, anti-anxiety medication, and sometimes even cognitive behavior therapy (CBT). All these are worth a look-see.

Good luck to you, and I'm happy to learn everything seems to be in order. If one has to have attention drawn to the heart, it's good to know at least the heart is heatlthy, even if symptoms are unnerving. As you say, you can know you're not going to drop over, and that's worth a lot!

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