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Risk stratification and prevention of ventricular arrhythmias in mitral valve prolapse
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O prolapso da válvula mitral (MVP) é uma doença valvular comum, com uma prevalência estimada entre 2 e 3% na população geral, que consiste num deslocamento ≥2 mm de um ou ambos os folhetos além do anel mitral em direcção à aurícula esquerda durante a sístole.
Estudos recentes esclarecem a associação entre o MVP e o desenvolvimento de arritmias ventriculares (VA) e, consequentemente, morte súbita cardíaca (SCD). Vários marcadores de risco foram identificados, incluindo a gravidade da regurgitação mitral (MR), a presença de disjunção anular mitral (MAD), flail, redundância e/ou espessamento dos folhetos, prolapso de ambos os folhetos, anomalias electrocardiográficas (ondas T invertidas ou bifásicas, complexos ventriculares prematuros (PVCs) e intervalos QT prolongados) e a presença de fibrose em torno dos músculos papilares (PMs), anel mitral ou parede inferobasal do ventrículo esquerdo.
O termo arrhythmic MVP refere-se a um conjunto específico de indivíduos com MVP com um risco aumentado de desenvolver arritmias e eventos cardíacos adversos. Este fenótipo é caracterizado pela presença de MVP, independentemente da existência de MR, por frequentes extrassístoles ventriculares, com origem próxima aos PMs ou à parede inferobasal do ventrículo esquerdo, ou por arritmias ventriculares complexas (VAs).
Este trabalho realça a importância da variedade de recursos imagiológicos e descreve as vantagens dos mais recentes exames de diagnóstico e a forma como melhoraram o conhecimento sobre esta patologia. A utilização de electrocardiografia (ECG), Holter, ecocardiografia, ressonância magnética cardíaca (CMR), entre outros, desempenham um papel importante na gestão do MVP, através da avaliação da anatomia, quantificação da RM e fibrose miocárdica.
A incorporação de algoritmos de estratificação de risco na prática clínica permite aos profissionais de saúde melhorar estratégias de gestão e ter uma base mais fundamentada para a decisão terapêutica: farmacológica, ablação por cateter (CA), cirurgia valvular ou implante de cardioversor desfibrilhador implantável (ICD) em doentes de alto risco. Realizar uma estratificação de risco é indispensável para melhorar os resultados dos doentes e ajudar a prevenir eventos adversos associados ao MVP.
Mitral valve prolapse (MVP) is a common valvular disorder, with estimates ranging from 2 to 3% in the general population, that consists in a superior displacement of at least 2 mm of one or both leaflets beyond the mitral annulus into the left atrium (LA) during systole. Recent studies have shed light on the association between MVP and the development of ventricular arrhythmia (VA), including sudden cardiac death (SCD). Several risk markers have been identified, including mitral regurgitation (MR) severity, presence of mitral annular disjunction (MAD), flail, redundant and/or thickened leaflets, electrocardiographic abnormalities (such as inverted or biphasic T waves, premature ventricular complexes (PVCs) and prolonged QT intervals) and the presence of fibrosis surrounding the papillary muscles (PMs), mitral annulus or inferobasal wall. The term arrhythmic MVP refers to a specific subset of individuals with MVP who exhibit a higher risk of developing arrhythmias and adverse cardiac events. This phenotype is characterized by the presence of MVP, regardless of MR, accompanied by frequent PVCs, originating near the PMs or the inferobasal left ventricular wall, or complex ventricular arrhythmias (VAs). This work highlights the importance of multimodality imaging and further describes the advantages of the most recent diagnostic tools and how they improved the knowledge about this condition. The use of electrocardiography (ECG), Holter monitoring, echocardiography, including transthoracic and transoesophageal approaches, cardiac magnetic resonance (CMR) among others play an important role in MVP management, by assessing the anatomy, MR quantification and myocardial fibrosis. Incorporating risk stratification algorithms into clinical practice allows healthcare professionals to enhance management strategies and have a more solid therapeutic decision, between medical therapy, catheter ablation (CA), valve surgery or implantable cardioverter defibrillator (ICD) placement in high-risk patients. A comprehensive approach to risk stratification and management can improve patient outcomes and help prevent adverse events associated with MVP.
Mitral valve prolapse (MVP) is a common valvular disorder, with estimates ranging from 2 to 3% in the general population, that consists in a superior displacement of at least 2 mm of one or both leaflets beyond the mitral annulus into the left atrium (LA) during systole. Recent studies have shed light on the association between MVP and the development of ventricular arrhythmia (VA), including sudden cardiac death (SCD). Several risk markers have been identified, including mitral regurgitation (MR) severity, presence of mitral annular disjunction (MAD), flail, redundant and/or thickened leaflets, electrocardiographic abnormalities (such as inverted or biphasic T waves, premature ventricular complexes (PVCs) and prolonged QT intervals) and the presence of fibrosis surrounding the papillary muscles (PMs), mitral annulus or inferobasal wall. The term arrhythmic MVP refers to a specific subset of individuals with MVP who exhibit a higher risk of developing arrhythmias and adverse cardiac events. This phenotype is characterized by the presence of MVP, regardless of MR, accompanied by frequent PVCs, originating near the PMs or the inferobasal left ventricular wall, or complex ventricular arrhythmias (VAs). This work highlights the importance of multimodality imaging and further describes the advantages of the most recent diagnostic tools and how they improved the knowledge about this condition. The use of electrocardiography (ECG), Holter monitoring, echocardiography, including transthoracic and transoesophageal approaches, cardiac magnetic resonance (CMR) among others play an important role in MVP management, by assessing the anatomy, MR quantification and myocardial fibrosis. Incorporating risk stratification algorithms into clinical practice allows healthcare professionals to enhance management strategies and have a more solid therapeutic decision, between medical therapy, catheter ablation (CA), valve surgery or implantable cardioverter defibrillator (ICD) placement in high-risk patients. A comprehensive approach to risk stratification and management can improve patient outcomes and help prevent adverse events associated with MVP.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2023
Palavras-chave
Prolapso da válvula mitral Estratificação de risco Arritmia ventricular Morte súbita cardíaca Cardiologia