**6. Diagnostics**

It should be emphasized that the main method of diagnosis of mitral valve prolapse is currently two-dimensional echocardiography. However, certainly, it is necessary to take into account the history of the patient, including the family history, the presence of concomitant markers of connective tissue dysplasia, the presence of clinical manifestations of prolapse MV, including relatives, clarify the family thrombotic anamnesis or the presence of sudden deaths in relatives.

In most cases, the diagnosis of prolapse MV in pregnant women is established even before its onset. However, in a part of young primitive women—MVP—a random echocardiographic finding requires a careful evaluation of clinical and anamnestic risk factors in each pregnant woman [5, 33].

#### **6.1. Cardiac examination**

The most common auscultatory features of mitral valve prolapse are the non-ejection click (single or multiple) and the murmur of mitral regurgitation. The click is thought to be caused by snapping of the mitral chordae during systole when the valve bows into the atrium. The click is mobile, meaning its timing varies with maneuvers that change the left ventricular volume, occurring earlier in systole with sitting, standing, or other interventions that reduce ventricular size, or later with those interventions that increase the chamber size such as squatting (movie 4 and movie 5) [34]. An MVP click should be differentiated from the aortic or pulmonary ejection clicks (occurring early in systole, at the foot of the carotid upstroke) and from other cardiac sounds (split first or second heart sounds, pericardial sounds, atrial septal aneurysm clicks).

With a routine clinical examination and auscultation of cardiac tones, a systolic click is heard between the I and II heart tones, together or without middle diastolic or late systolic murmur, which is a characteristic symptom. The presence of these auscultative data may vary depending on the position of the body of the pregnant woman or the degree of her hydration. Similar auscultative changes can occur in healthy women during pregnancy, varying in the time of click occurrence and in mitigating or shortening the time of noise, and when series of echocardiographic studies in the presence of MPV in some women EchoCG signs of it disappear [6].

#### **6.2. Diagnostic imaging techniques**

**6.** the vegetative crises (sympathetic-adrenal, vago-insular, mixed). These are the most strik-

**7.** the mental disorders: neurasthenia, anxiety disorders, anxiety-phobic disorders, mood disorders. When assessing the results of a comprehensive psychological examination, it was found that in persons with mitral valve prolapse, there are a number of distinguishing features from healthy people: inadequate self-esteem (32.1%), low level and inadequacy of attitudes (50.9%), high situational anxiety (32.7%), low emotional stability (39.0%), and a

Along with the widespread point of view about the propensity of patients with mitral valve prolapse to hypotension, recently there have been isolated reports of the presence of arterial hypertension in patients with prolapse of the mitral valve [5]. The possibility of hereditary predisposition to arterial hypertension, mixed with hereditary pathology of connective tissue,

However, not all authors agree with the presence of MPV syndrome with the above-described clinical symptoms [3], believing that PMC is only an anatomical feature of the valve structure, if it is not a manifestation of the Martha syndrome. Clinical manifestations of approximately

It should be emphasized that the main method of diagnosis of mitral valve prolapse is currently two-dimensional echocardiography. However, certainly, it is necessary to take into account the history of the patient, including the family history, the presence of concomitant markers of connective tissue dysplasia, the presence of clinical manifestations of prolapse MV, including relatives, clarify the family thrombotic anamnesis or the presence of sudden

In most cases, the diagnosis of prolapse MV in pregnant women is established even before its onset. However, in a part of young primitive women—MVP—a random echocardiographic finding requires a careful evaluation of clinical and anamnestic risk factors in each pregnant

The most common auscultatory features of mitral valve prolapse are the non-ejection click (single or multiple) and the murmur of mitral regurgitation. The click is thought to be caused by snapping of the mitral chordae during systole when the valve bows into the atrium. The click is mobile, meaning its timing varies with maneuvers that change the left ventricular volume, occurring earlier in systole with sitting, standing, or other interventions that reduce ventricular size, or later with those interventions that increase the chamber size such as squatting (movie 4 and movie 5) [34]. An MVP click should be differentiated from the aortic or

equal frequency are observed in women with and without EchoCG signs of MPV.

decrease in the dynamic indicators of mental activity [6].

ing manifestations of MVP;

86 Structural Insufficiency Anomalies in Cardiac Valves

is not excluded.

**6. Diagnostics**

deaths in relatives.

woman [5, 33].

**6.1. Cardiac examination**

In most pregnant women who do not show any other clinical signs, so in the absence of significant regurgitation in *echocardiography*, women should talk about the safety of pregnancy and childbirth, as well as the absence of a negative effect on the fetus of this condition [3]. MVP is diagnosed at the maximum systolic displacement of the mitral valve flaps beyond the ring line in the parasternal longitudinal position by more than 2 mm. The use of the parasternal longitudinal section for the diagnosis of MVP is due to the peculiarities of the shape of the mitral valve ring, while the isolated displacement of the anterior valve beyond the ring line seen in the four-chamber apex position is the main cause of its overdiagnosis. In echocardiographic conclusion, it is necessary to indicate the depth of prolapse, the length and thickness of each of the valves, and the degree of mitral regurgitation [6, 12] (**Figure 2**).

The normal length of the front leaf is 21–24 mm, the rear is 12–14 mm. Depending on the thickness of the leaf, the classic MPV is distinguished, with a valve thickness of more than 5 mm in diastole (reflects the presence of myxomatous degeneration of the valves) and nonclassical MPV—with a thickness of less than 5 mm.

The determination of the degree of mitral regurgitation is currently conducted according to the recommendations of the ANA/ACC [6]. For this purpose, the following qualitative indices are used: the diameter of the vein of the regurgitation jet (vena contracta), the volume of regurgitation, and the area of the regurgitation opening calculated according to the area of the proximal equal-velocity surface (PISA). Specific for MPV is the mitral regurgitation that occurs at the end of the systole; it is usually high speed and eccentric.

The evaluation of LV systolic function is also an important component of EchoCG study. It is an important prognostic factor in patients with MVP and severe MH [6, 12]. There is evidence of worsening of LV systolic function in young patients with MVP and without significant mitral regurgitation [35].

The development of 3D technology, especially real-time 3D-TEE, provides excellent rendering of the mitral valve complex. Live 3D-TEE has become routine in pre/intraoperative imaging of the mitral valve and in percutaneous mitral valve interventions. 3D-TEE efficiently identifies

assessment of the mitral valve anatomy (annulus area and perimeter, inter-commissural and septal-lateral diameters) becomes increasingly important. These can be reliably measured

Mitral Valve Prolapse in Pregnancy: Modern Concept http://dx.doi.org/10.5772/intechopen.76692 89

While 2D and 3D imaging techniques allow identification of anatomical substrate, Doppler echocardiographic techniques are key to estimating the severity of MR. The criteria used to

MR severity should be quantitated in all patients with a visual appearance of greater than mild MR on color Doppler. Formal quantification of mitral valve severity not only minimizes errors intrinsic to color Doppler visual quantification of severity but also provides essential information about a patient's individual risk. Quantitative measures of MR (regurgitant volume and orifice) are essential predictors of outcome [36] as confirmed in two independent

In a dynamic echocardiographic study in pregnant women with prolapse of the mitral valve of women, there are stable sizes of the left chambers of the heart, as well as the thickness of the left ventricular myocardium and the interventricular septum throughout the period of pregnancy and in the postpartum period [5]. With an increase in the period of pregnancy from the first to third trimester, there is a natural increase in the frequency of a greater degree of prolapse of the mitral valve and to a lesser extent the degree of mitral regurgitation.

In accordance with the generally accepted approaches, the stratification of the risk of cardiovascular complications and death in patients with MVP should be based, first of all, on the evaluation of the severity of mitral regurgitation and the thickness of the mitral valve leaf [5, 6, 33]. The latter characterizes the presence and severity of their myxomatous degeneration. With a leaf thickness of 5 mm or more, the total probability of sudden death, endocarditis, and cerebral embolism, the likelihood of developing mitral insufficiency, rupture of chords, and ventricular

The degree of risk was determined in the presence and severity of a number of factors: the auscultatory pattern, the degree of prolapse, the severity of myxomatic degeneration of the valves, mitral regurgitation, age, fibrillation of pre-arthies, chronic heart failure, hyperten-

Most patients with MVP, without signs of MR and mild MR, can be classified as low risk with a favorable prognosis [3, 10, 15]. Life expectancy at them corresponds to that in the general population [20]. The unfavorable course of MVP is the increase in MR, leading to dilatation of the LV and LP, development of atrial fibrillation, LV systolic dysfunction, and chronic heart failure. The onset and rapid progression of MP may be due to the rupture of myxomatologi-

The presence of altered valves with MVP increases the risk of infectious endocarditis, although overall its probability in the population of patients with MVP is low [39]. Thromboembolism of cerebral vessels is the main cause of neurologic symptoms (transient ischemic attacks and strokes) in patients with MVP, and the risk of embolism is higher than in the general population [3, 6, 10]. Sudden death is a rare complication of primary MVP (less than 2% of cases with prolonged follow-up, with an annual mortality of less than 1%). The main cause of sudden

arrhythmias in such patients can be attributed to the high-risk group [6, 10, 12, 13, 37].

by both 3D echocardiography and computed tomography (CT).

prospective studies totaling more than 1000 patients followed long term.

diagnose severe MR are discussed separately.

sion, and others [38].

cally altered chords [6].

**Figure 2.** Echocardiography in mitral valve prolapse.

correct location of prolapse and flail segments, and by reconstruction of the 3D image from the left atrial view (surgical view), information is easily communicated to the surgical team. In a study comparing 2D TEE with 3D-TEE, both expert and less experienced echocardiographers more accurately described the mitral valve pathology using 3D-TEE (with surgical pathology as the reference), with less experienced interpreters gaining a significantly greater advantage from using 3D-TEE [36]. 3D-TEE is the key imaging modality for guidance of percutaneous mitral valve repair with the MitraClip system.

With increased use of 3D-TEE, cleft-like indentations of the posterior mitral leaflet are more frequently recognized and may be present in up to one-third of patients with myxomatous MVP [36]. Appropriate recognition of cleft-like indentation is important when planning surgical or percutaneous mitral valve repair. However, it must be emphasized that not all cleftlike indentations apparent on 3D reconstruction are associated with mitral regurgitation (i.e., many are "non-functional" clefts, being visible only during diastole, which do not require a repair). The best approach to determine the significance of cleft-like indentation is to examine the mitral valve anatomy from the left ventricular en-face view, in both 3D and 3D color.

3D-TEE also allows insights into the dynamic mitral annulus function, with early-systolic area contraction and saddle-shape deepening contributing to mitral competency. The mitral annulus in MVP is also dynamic but considerably different from normal patients, with loss of early-systolic area contraction and diminished saddle-shape deepening despite similar magnitude of ventricular contraction, suggestive of ventricular-annular decoupling [36]. With the rapid development of percutaneous interventions for mitral regurgitation, accurate assessment of the mitral valve anatomy (annulus area and perimeter, inter-commissural and septal-lateral diameters) becomes increasingly important. These can be reliably measured by both 3D echocardiography and computed tomography (CT).

While 2D and 3D imaging techniques allow identification of anatomical substrate, Doppler echocardiographic techniques are key to estimating the severity of MR. The criteria used to diagnose severe MR are discussed separately.

MR severity should be quantitated in all patients with a visual appearance of greater than mild MR on color Doppler. Formal quantification of mitral valve severity not only minimizes errors intrinsic to color Doppler visual quantification of severity but also provides essential information about a patient's individual risk. Quantitative measures of MR (regurgitant volume and orifice) are essential predictors of outcome [36] as confirmed in two independent prospective studies totaling more than 1000 patients followed long term.

In a dynamic echocardiographic study in pregnant women with prolapse of the mitral valve of women, there are stable sizes of the left chambers of the heart, as well as the thickness of the left ventricular myocardium and the interventricular septum throughout the period of pregnancy and in the postpartum period [5]. With an increase in the period of pregnancy from the first to third trimester, there is a natural increase in the frequency of a greater degree of prolapse of the mitral valve and to a lesser extent the degree of mitral regurgitation.

In accordance with the generally accepted approaches, the stratification of the risk of cardiovascular complications and death in patients with MVP should be based, first of all, on the evaluation of the severity of mitral regurgitation and the thickness of the mitral valve leaf [5, 6, 33]. The latter characterizes the presence and severity of their myxomatous degeneration. With a leaf thickness of 5 mm or more, the total probability of sudden death, endocarditis, and cerebral embolism, the likelihood of developing mitral insufficiency, rupture of chords, and ventricular arrhythmias in such patients can be attributed to the high-risk group [6, 10, 12, 13, 37].

correct location of prolapse and flail segments, and by reconstruction of the 3D image from the left atrial view (surgical view), information is easily communicated to the surgical team. In a study comparing 2D TEE with 3D-TEE, both expert and less experienced echocardiographers more accurately described the mitral valve pathology using 3D-TEE (with surgical pathology as the reference), with less experienced interpreters gaining a significantly greater advantage from using 3D-TEE [36]. 3D-TEE is the key imaging modality for guidance of per-

With increased use of 3D-TEE, cleft-like indentations of the posterior mitral leaflet are more frequently recognized and may be present in up to one-third of patients with myxomatous MVP [36]. Appropriate recognition of cleft-like indentation is important when planning surgical or percutaneous mitral valve repair. However, it must be emphasized that not all cleftlike indentations apparent on 3D reconstruction are associated with mitral regurgitation (i.e., many are "non-functional" clefts, being visible only during diastole, which do not require a repair). The best approach to determine the significance of cleft-like indentation is to examine the mitral valve anatomy from the left ventricular en-face view, in both 3D and 3D color.

3D-TEE also allows insights into the dynamic mitral annulus function, with early-systolic area contraction and saddle-shape deepening contributing to mitral competency. The mitral annulus in MVP is also dynamic but considerably different from normal patients, with loss of early-systolic area contraction and diminished saddle-shape deepening despite similar magnitude of ventricular contraction, suggestive of ventricular-annular decoupling [36]. With the rapid development of percutaneous interventions for mitral regurgitation, accurate

cutaneous mitral valve repair with the MitraClip system.

**Figure 2.** Echocardiography in mitral valve prolapse.

88 Structural Insufficiency Anomalies in Cardiac Valves

The degree of risk was determined in the presence and severity of a number of factors: the auscultatory pattern, the degree of prolapse, the severity of myxomatic degeneration of the valves, mitral regurgitation, age, fibrillation of pre-arthies, chronic heart failure, hypertension, and others [38].

Most patients with MVP, without signs of MR and mild MR, can be classified as low risk with a favorable prognosis [3, 10, 15]. Life expectancy at them corresponds to that in the general population [20]. The unfavorable course of MVP is the increase in MR, leading to dilatation of the LV and LP, development of atrial fibrillation, LV systolic dysfunction, and chronic heart failure. The onset and rapid progression of MP may be due to the rupture of myxomatologically altered chords [6].

The presence of altered valves with MVP increases the risk of infectious endocarditis, although overall its probability in the population of patients with MVP is low [39]. Thromboembolism of cerebral vessels is the main cause of neurologic symptoms (transient ischemic attacks and strokes) in patients with MVP, and the risk of embolism is higher than in the general population [3, 6, 10]. Sudden death is a rare complication of primary MVP (less than 2% of cases with prolonged follow-up, with an annual mortality of less than 1%). The main cause of sudden cardiac death in MVP is ventricular tachyarrhythmias, which are especially common in family MVP forms [3, 10]. In a number of cases in the presence of pain in the left half of the chest, in women, there is an inversion of the T-wave on the ECG, especially in the II and III thoracic leads, even in the presence of normal coronary angiography. When conducting a treadmill test, it is also possible to detect the depression of the ST segment, indistinguishable from that of myocardial ischemia.

In women older than 30 years, WLA occurs two times more often than in women at the age of 20–25. WLA leads to a prolonged course or complete stopping of labor, the appearance of signs of distress syndrome of the fetus, which causes operative delivery. In the structure of an emergency cesarean section, the WLA occupies the second to third place,

Mitral Valve Prolapse in Pregnancy: Modern Concept http://dx.doi.org/10.5772/intechopen.76692 91

The investigation of the causes of WLA concerns mainly the issue of the state of the myometrium without sufficient attention to the general anamnestic and clinical signs inherent in the MVP, although the causative factors of the WLA may indicate the possible involvement of

The study of the features of the course of pregnancy and childbirth of women with small and large signs of MVP and CTD made it possible to establish that anomalies of labor in the first stage of childbirth appeared in 85.2% of women giving birth, compared to 33.9% in the control group without CDT. Cesarean section in the main group was performed in 12% of pregnant women and only in 4% of patients in the control group. Hypotonic bleeding in the III stage of labor took place in 7.3% of mothers with MVP and CTD and were absent in the control group. The discrepancy of the pubic joint was diagnosed in 7.2% of women with MVP and CTD and

The birth traumatism of newborns from mothers with MVP and CTD was diagnosed in 34.4% of cases compared with 3.4% in the control group. This study showed that patients with generalized manifestations (involvement of three or more organs in the connective tissue defect) of MVP and CTD even in the absence of severe forms of this pathology constitute a high-risk

The frequent occurrence of MVP and CDT in pediatric practice, the pronounced clinical polymorphism, and multiple organ changes make the problem relevant from the point of view of

Hemodynamic changes that develop during pregnancy, during childbirth, and in the postpartum period (primarily changes in bcc and cardiac ejection) cannot but affect the current of the woman's cardiovascular diseases. As well as diseases of the heart and blood vessels can adversely affect the course of pregnancy. Changes in hemodynamics in the mother have a negative effect on uteroplacental blood circulation, which in some cases may lead to the development of placental insufficiency, fetal growth retardation (FGR), and premature birth [4, 7, 16]. The central hemodynamics in women with mitral valve prolapse in the III trimester is characterized by an increase in the overall peripheral resistance of the vessels against a background of a decrease in volume indices, which indicates the voltage of the compensa-

The features of hemodynamics (heart rate, peripheral resistance of blood vessels, changes in blood pressure) are due to changes in the activity of the sympathoadrenal system. The pregnant women with MVP showed a significant decrease in MI and BV, as well as CI and BI as compared to those in women without MVP with a physiological pregnancy. Perhaps, the reduction of these indicators is due to a decrease in the contractility of the myocardium and a decrease in the activity of the sympathoadrenal system. Formation in the first trimester of

MVP in the pathogenesis of an abnormality of labor [16].

group for the formation of obstetric and neonatal pathology.

tory-adaptive mechanisms of the cardiovascular system [33].

was not detected in the control group.

differential diagnostics and complex therapy.

reaching 37%.
