Mitral Valve Prolapse: Truth vs. Fiction
"There is nothing to fear except the persistent refusal to find
out the truth." - Dorothy Thompson
One of the chapters in my recent book, "Courageous
Confrontations," describes my experience with a patient named
Emma Jorgenson. Shortly after sitting down in my consultation
room, she said, "I hope you can help me, Doctor. Those other
doctors keep saying that my symptoms are all in my head."
"What seems to be bothering you, Emma?"
"Bothering me? My problems aren't just bothering me, they're
killing me. If you don't do something to help me, I am going to
die. I just know it."
"What kind of symptoms are you having?"
Heaving a huge sigh, Emma shifted uncomfortably in her chair. "I
don't know where to begin," she said. "Whenever I try to explain
my symptoms to a doctor, he just rolls his eyes, and tells me
it's nothing to worry about." Emma hunched over, and began to
well up.
I reached for the box of tissues on my desk and handed them to
Emma. "Let's figure out how we can help you. How about starting
at the beginning?" I said. "What was your first symptom?"
"One night, about three years ago, I woke up with a pounding
sensation in my chest. My heart was racing so fast, I thought it
was going to jump out of my chest. Then I began to get nauseous
and dizzy. I called Dr. Cahill, my family doctor who's also my
gynecologist, and when I went in to see her the next day, she
found a tumor in my tummy. She said I needed to have an
operation to remove it."
"What did she find?"
"A cyst on my ovary. It was nothing serious, but after the
operation, the pounding and the dizziness became more frequent,
so she sent me to a neurologist."
"Why a neurologist?"
"I'd read an article that said the three most common symptoms of
brain tumors were headaches, nausea and dizziness, so I asked
her to send me to a specialist. He did a bunch of scans and
electrical tests, and said everything was okay. He prescribed a
tranquilizer, but I knew that wasn't going to solve my problem."
"Did the tranquilizer help?"
"A little at first, but then my symptoms got worse. When the
pounding started, in addition to becoming dizzy and nauseous, my
hands would begin to tingle and become numb. After a while, the
numbness spread to my face. The whole area around my mouth would
lose all feeling, except for a wired tingling sensation. I was
sure I going to have a stroke. That's when Dr. Cahill referred
me to an ENT doctor."
"An Ears, Nose and Throat doctor?"
"That's right. She thought my dizziness might be due to an inner
ear problem. He examined me and said he wasn't sure what was
going on, but that I needed an operation to get to the bottom of
it. But I was too scared. Besides, I still hadn't recovered from
the ovary surgery, and my wounds weren't healing right, so my
gynecologist said that I could wait before having another
operation."
Emma's story made me wince. She had unwittingly fallen into the
maze of modern medicine. Each specialist viewed her symptoms
through the prism of his own specialty, ordered the inevitable
battery of tests, and treated her with a pill or a procedure
without having a diagnosis. Medications are the fifth leading
cause of preventable death in the United States.
"Why did she send you to me?"
"I told her I didn't think I had an inner ear problem, and that
it had to be some kind of a heart condition. After all, how
could an inner ear problem cause chest pains and shortness of
breath?"
"Chest pain and shortness of breath? You didn't say anything
about that."
I explained that there are several causes for chest discomfort,
and each has a telltale set of characteristics. For example, in
patients with pleurisy, an inflammation of the lining of the
lungs, pain occurs with deep breaths. With an inflammation of
the sac around the heart, called pericarditis, the pain
increases when a patient lies down, and improves when they sit
up and lean forward. In patients with blocked coronary arteries,
the discomfort occurs during physical activity, like walking or
climbing stairs. A bulging or tear in the aorta, the main artery
in the body, also has characteristic features.
All these possibilities and more needed to be carefully explored
by delving into the nuances of Emma's chest pain, as well as her
palpitations and shortness of breath. Emma's description of her
chest pains did not conform to any of the common causes of chest
discomfort, but it was important not to overlook other serious
possibilities. In patients with pleuritis a rubbing sound can be
heard with a stethoscope over the lungs during a deep
inhalation. Pericarditis sounds like sandpaper being rubbed in
synchrony with the heartbeat. Cardiac birth defects, diseases of
the heart muscle, and valve abnormalities all provide telltale
murmurs and other characteristic clues on the physical exam.
Despite Emma's rapid pulse, her blood pressure was normal and
her lungs sounded clear. On the cardiac exam, her heart impulse
was normal, but when I placed the stethoscope under her left
breast, the diagnosis immediately became obvious.
When Emma's heart contracted, a series of loud clicking sounds
were audible. My patient had mitral valve prolapse.
The heart is divided into two sides, each having four chambers.
The upper two are called atria, and the lower two are the
ventricles. The right atrium and ventricle receives
oxygen-depleted blood from the body and sends it to the lungs
where its oxygen content is replenished. The left atrium then
receives the rejuvenated blood, passing it along to the left
ventricle. The powerful left ventricular chamber then pumps its
contents back to the body.
The atria and ventricles are separated from each other by
valves. The tricuspid valve is located on the right side of the
heart, while the mitral valve resides on the left. When the
mitral valve opens, blood exits the left atrium, travels through
the valve, and enters the left ventricle. As the left ventricle
begins to contract, the valve closes, preventing blood from
moving backwards into the left atrium.
The mitral valve consists of two leaflets, or flaps, each in the
shape of a parachute. Normally, both leaflets close in unison,
but in patients with mitral valve prolapse, either the valve
leaflets are too large, the chords that attach them to the heart
are too long, or the connective tissue in the structure are more
elastic than normal. In any case, one or both of them balloons,
or flops--prolapsing into the left atrium. The characteristic
click heard when listening to the heart is caused by the sound
of the valve leaflet prolapsing into the atrial chamber, much
like a parachute in the wind.
Mitral valve prolapse is a relatively common condition,
occurring in two and a half to five percent of people in the
United States. It is particularly prevalent in pre-menopausal
women between the ages of fourteen and forty. There has been a
considerable amount of speculation about how the valve
abnormalities occur, but recent research has shown that there is
a genetic predisposition for the syndrome. Between twenty and
fifty percent of the relatives of mitral valve prolapse patients
also have the syndrome.
Echocardiograms are a valuable means of evaluating patients with
suspected mitral valve prolapse. The test confirms the diagnosis
by demonstrating the prolapsing valve leaflets. In addition, the
presence and severity of any blood leaking backwards across the
valve from the ventricle to the atrium can also be detected. In
Emma's case, I did not hear the telltale murmur suggesting the
presence of a leak.
Patients with mitral valve prolapse often have symptoms that
mimic serious illnesses like heart attacks and cardiac rhythm
abnormalities, but in the vast majority of women, the condition
is neither dangerous nor life threatening. Most of the close
relatives of patients with mitral valve prolapse who demonstrate
a floppy valve on echocardiography are completely free of
symptoms.
The reason for the chest pains, palpitations, or shortness of
breath that occur in some patients with mitral valve prolapse
has never been understood. For want of a more scientific
explanation, it has been hypothesized that, their nervous
systems are programmed to respond excessively to stress. For
unknown reasons, they are triggered to react to unthreatening
circumstances as though they were dangerous. This imbalance is
called dysautonomia.
After putting my stethoscope in the pocket of my lab coat, I
patted Emma gently on the shoulder. "I have wonderful news! Your
symptoms are being caused by a benign condition called mitral
valve prolapse." I assumed that Emma would be relieved. Instead,
the diagnosis increased her anxiety to the point where she
became a shut-in.
While the symptoms of mitral valve prolapse are divers and can
be frighteningly severe, it is important to emphasize that for
the overwhelming majority of individuals with the condition, it
is neither dangerous nor life-threatening. Studies have found
that increase levels of circulating adrenalin like substances
account for the symptoms of chest pains, palpitations, shortness
of breath, anxiety and panic attacks that plague people with the
problem.
The outlook for the great majority of people with mitral
prolapse is excellent. My experience has been that those with
debilitating symptoms gradually do feel better over time. They
come to realize that their symptoms will not result in a heart
attack or sudden death, and the symptoms themselves then become
less incapacitating. As one of my patients said, "I just put the
pains in my handbag and went about my business."
For most patients, the only treatment necessary is the use of
prophylactic antibiotics before various types of surgery and
dental work, but this is used only in those who have a leaking
valve. Medication, particularly a group of drugs called "beta
blockers" can be useful to control debilitating symptoms.
Exercise, a healthy diet and relaxation techniques have all been
useful in controlling symptoms.
And as for Emma, she had a transformative experience that
changed her life. No longer immobilized by fear, she developed a
remarkable new equanimity and a new appreciation of life.
It also gave her a new life purpose. Emma became a patient care
counselor and an invaluable member of our health care team,
using her experience as a resource to counsel our fear-ridden
patients.