Classification of mitral valve prolapse.

The scope of diagnosing mitral valve prolapse (MVP) has been enlarged by the earlier reported real-time B-scan criteria of small or "localised MVP". This form is believed to be the precursor of the overt MVP which is then readily diagnosed by angiocardiography and 1- and 2-dimensional echocardiography (1- and 2-dE). Rheumatic heart disease (RHD) is believed to be recognisable much earlier as well, by the previously reported 1- and 2-dE features of "early commissural fusion" (ECF). 30 patients in whom overt or localised MVP were diagnosed previously were reviewed for overt or early signs of ECF. In all patients early or overt echo features of RHD could be visualised. Thus RHD may be the most important cause of acquired MVP, even though it is rarely considered in recent classifications. It is proposed that RHD is perhaps the unifying link for all forms of MVP. GOTTLIEB and CHUNG were asking for such a unifying link "since the present classification is dubious at best. It offers nothing to use clinically and may actually be in error, since the primary form may be a less overt expression of the secondary form." It is proposed that mostly unrecognised rheumatic fever may be the underlying first lesion leading to the various different mechanisms described for MVP. If this can be confirmed, a new approach to primary prevention of rheumatic fever and its subclinical forms may be necessary. There is also some evidence to suggest that RHD may be the early and unrecognised microlesion in the coronary arteries as well and thus the important early factor in the development of macroscopic coronary artery disease.