Mitral valve prolapse as cause of terminal ventricular complex ischaemia: a clinical case

Background. Mitral valve prolapse has common prevalence of 1% in population. Patients with mitral valve prolapse (MVP) continue to pose a major challenge in practical cardiology for its nonspecific manifestations, usually, palpitations and atypical chest pain. Several studies have demonstrated a high incidence of ventricular arrhythmias in individuals with MVP. MVP was observed in 2.3% of patients with sudden cardiac death. Comparing to the common population with sudden cardiac death, MVP patients belonged to a younger age group and less frequently had concomitant cardiovascular pathology.

Clinical Case Description. Patient T. referred with complaints of transient constricting chest pain at rest and exercise, dyspnoea at exercise. A total duration of ST-T segment displacement episodes was 168 min, with painless episodes prevailing. Spiral computed angiography did not reveal calcinosis, soft coronary atherosclerotic plaques or abnormal arterial origins. Severe ventricular repolarisation abnormalities with sinusoidal T-U waves morphology in MVP are harbingers of sudden cardiac death, despite a normal QT interval duration. The T wave inversion in the lower lead and ventricular extrasystole also comprise the risk factors for sudden cardiac death in patients with MVP.

Conclusion. Mitral valve prolapse caused an ischaemic ST-T segment depression in a young woman indicating a high risk of sudden cardiac death and need for immediate drug therapy. The Russian recommendations on treatment of connective tissue dysplasia and known literature suggest magnesium preparations as a preferred medication. Beta-blockers are effective in increased sympathetic nervous system reactivity or tone. Collagen synthesis stimulators, vitamins C, D, P, group B, preparations of magnesium, calcium, manganese, copper and antihypoxants are also recommended. Treatment with bisoprolol and magnesium orotate eliminated ischaemia and ventricular extrasystoles and improved the patient’s condition.

1. Delling F.N., Rong J., Larson M.G., Lehman B., Osypiuk E., Stantchev P., Slaugenhaupt S.A., Benjamin E.J., Levine R.A., Vasan R.S. Familial clustering of mitral valve prolapse in the community. Circulation. 2015; 131(3): 263-268. DOI: 10.1161/CIRCULATION-AHA.114.012594

2. Basso C., Perazzolo Marra M., Rizzo S., De Lazzari M., Giorgi B., Cipriani A., Frigo A.C., Rigato I., Migliore F., Pilichou K., Bertaglia E., Cacciavillani L., Bauce B., Corrado D., Thiene G., Iliceto S. Arrhythmic Mitral Valve Prolapse and Sudden Cardiac Death. Circulation. 2015; 132(7): 556-566. DOI: 10.1161/CIRCULATIONAHA.115.016291

3. Narayanan K., Uy-Evanado A., Teodorescu C., Reinier K., Nichols G.A., Gunson K., Jui J., Chugh S.S. Mitral valve prolapse and sudden cardiac arrest in the community. Heart. Rhythm. 2016; 13(2): 498-503. DOI: 10.1016/j.hrthm.2015.09.026

4. Sumin A.N. The assessment of pretest probability in obstructive coronary lesion diagnostics: unresolved issues. Russian Journal of Cardiology. 2017; (11): 6876 (In Russ., English abstract). DOI: 10.15829/15604071-2017-11-68-76

5. Knuuti J., Wijns W., Saraste A., Capodanno D., Barbato E., Funck-Brentano C., Prescott E., Storey R.F., Deaton C., Cuisset T., Agewall S., Dickstein K., Edvardsen T., Escaned J., Gersh B.J., Svitil P., Gilard M., Hasdai D., Hatala R., Mahfoud F., Masip J., Muneretto C., Valgimigli M., Achenbach S., Bax J.J.; ESC Scientific Document Group. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes .Eur. Heart J. 2020; 41(3): 407-477. DOI: 10.1093/eurheartj/ehz425

6. Reeva S.V., Malev E.G., Timofeev E.F., Pankova I.A., Zaripov B.I., Belousova T.I., Zemtsovsky E.V. Vegetative dysfunction and repolarization disorders on resting ecg and in exertion in younger persons with marfanoid phenotype and mitral valve prolapse. Russian Journal of Cardiology. 2015; (7): 84-88 (In Russ., English abstract). DOI: 10.15829/1560-40712015-7-84-88

7. van der Wall E.E., Schalij M.J. Mitral valve prolapse: a source of arrhythmias? Int. J. Cardiovasc. Imaging. 2010; 26(2): 147-149. DOI: 10.1007/s10554-009-9540-4

8. Extramiana F., Milleron O., Elbitar S., Uccellini A., Langeois M., Spentchian M., Delorme G., Arnoult F., Denjoy I., Bouleti C., Fressart V., Iserin F., Maison-Blanche P., Abifadel M., Leenhardt A., Boileau C., Jondeau G. High prevalence of ventricular repolarization abnormalities in people carrying TGFeR2 mutations. Sci. Rep. 2018; 8(1): 13019. DOI: 10.1038/s41598-018-31298-5

9. Alqarawi W., Birnie D.H., Burwash I.G. Mitral valve repair results in suppression of ventricular arrhythmias and normalization of repolarization abnormalities in mitral valve prolapse. HeartRhythm. Case. Rep. 2018; 4(5): 191-194. DOI: 10.1016/j.hrcr.2018.02.012

10. Basso C., Iliceto S., Thiene G., Perazzolo Marra M. Mitral valve prolapse, ventricular arrhythmias, and sudden death. Circulation. 2019; 140(11): 952-964. DOI: 10.1161/CIRCULATIONAHA.118.034075

11. Zegri-Reiriz I., de Alarcon A., Munoz P., MartmezSelles M., Gonzalez-Ramallo V., Miro J.M., Falces C., Gonzalez Rico C., Kortajarena Urkola X., Lepe J.A., Rodriguez Alvarez R., Reguera Iglesias J.M., Navas E., Dominguez F., Garcia-Pavia P.; Spanish Collaboration on Endocarditis — Grupo de Apoyo al Manejo de la Endocarditis infecciosa en Espana (GAMES). Infective Endocarditis in Patients With Bicuspid Aortic Valve or Mitral Valve Prolapse. J. Am. Coll. Cardiol. 2018; 71(24): 2731-2740. DOI: 10.1016/j.jacc.2018.03.534

12. Miller M.A., Dukkipati S.R., Turagam M., Liao S.L., Adams D.H., Reddy V.Y. Arrhythmic Mitral Valve Prolapse: JACC Review Topic of the Week. J. Am. Coll. Cardiol. 2018; 72(23PtA): 2904-2914. DOI: 10.1016/j.jacc.2018.09.048

13. Lee A.P., Jin C.N., Fan Y., Wong R.H.L., Underwood M.J., Wan S. Functional implication of mitral annular disjunction in mitral valve prolapse: a quantitative dynamic 3D echocardiographic study. JACC Cardiovasc. Imaging. 2017; 10(12): 1424-1433. DOI: 10.1016/j.jcmg.2016.11.022

14. Nalliah C.J., Mahajan R., Elliott A.D., Haqqani H., Lau D.H., Vohra J.K., Morton J.B., Semsarian C., Marwick T., Kalman J.M., Sanders P. Mitral valve prolapse and sudden cardiac death: a systematic review and meta-analysis. Heart. 2019; 105(2): 144-151. DOI: 10.1136/heartjnl-2017-312932

15. Martynov A.I., Nechaeva G.I., Akatova E.V., Vershinina M.V., Viktorova I.A., Goltsova L.G., Gromova O.A., Delov R.A., Drokina O V., Druk I.V., Dubiley G.S., Ivanova D.S., Ivanova I.L., Kalinina I.Yu., Kononova N.Yu., Kudinova E.G., Lalov Yu.V., Lisichenko O.V., Loginova E.N., Lyalukova E.A., Maksimov V.N., Nagaeva T.A., Nadey E.V., Moskvina Yu.V., Pervichko E.I., Plotnikova O.V., Ponomareva D.A., Potapov V.V., Ryapolova E.A., Savelyeva I.V., Svechnikova N.N., Seleznev A.V., Semenkin A.A., Semenova E.V., Smolnova T.Yu., Smyalovsky V.E., Tereshchenko Yu.V., Troshin I.Yu., Tyurin A.V., Khusainova R.I., Tsukanov A.Yu., Chindareva O. I., Shilova M.A., Shupina M.I., Temnikova E.A., Temnikova E.A. Guidelines of the Russian scientific medical society of internal medicine on the diagnosis, treatment and rehabilitation of patients with the connective tissue dysplasia (first edition). Medical News of North Caucasus. 2018; 13(1-2); 137-209 (In Russ., English abstract). DOI: 10.14300/mnnc.2018.13037

16. Barbagallo M., Rodriguez D., Ligia J. Magnesium and health. Internal Medicine: Open Access. 2019; 9(2). DOI: 10.35248/2165-8048.19.9.e105