Differentials
Aortic valve disease
SIGNS / SYMPTOMS
Aortic ejection clicks occur earlier in systole than in MVP, best heard to the right of the upper sternum. Click timing not affected by dynamic manoeuvres.
INVESTIGATIONS
Echocardiogram is diagnostic for bicuspid aortic valve disease as there is a characteristic appearance of the aortic valve in this condition.
Pulmonic valve disease
SIGNS / SYMPTOMS
Pulmonic ejection clicks occur earlier in systole than in MVP, best heard to the left of the upper sternum. Click timing not affected by dynamic manoeuvres.
INVESTIGATIONS
Echocardiogram is diagnostic for pulmonic valvular disease as abnormal motion or Doppler findings associated with this valve are evident.
Atrial myxoma
SIGNS / SYMPTOMS
May have symptoms of weight loss, fever, malaise. Examination may reveal a diastolic tumour plop or diastolic murmur similar to mitral stenosis.
INVESTIGATIONS
Heterogeneous masses which may be sessile, typically in the left atrium. Transoesophageal echocardiogram may yield more detail than transthoracic echocardiogram. Laboratory evaluation may reveal leukocytosis.
Ischaemia-related mitral regurgitation (MR)
SIGNS / SYMPTOMS
History reveals previous myocardial infarction. Examination features are similar to MVP-related regurgitant murmurs. May be late systolic or holosystolic, which can mimic severe MVP-related MR. Absence of click.
INVESTIGATIONS
ECG reveals previous infarction. Echocardiogram findings may delineate papillary muscle dysfunction and left ventricular wall akinesis or dyskinesis. The posterior mitral valve leaflet shows restricted motion as compared with the excess motion seen in MVP.
Rheumatic heart disease-related MR
SIGNS / SYMPTOMS
History of group A streptococcal pharyngitis followed by migratory large-joint arthritis, fever, rash, and subcutaneous nodules. Rheumatic heart disease typically follows 1-2 decades later. Examination features are similar to MVP-related regurgitant murmurs. Usually holosystolic, which can mimic severe MVP-related MR. Absence of click.
INVESTIGATIONS
ECG may show heart block. Echocardiogram is diagnostic with evidence of restricted motion of both leaflets. A degree of stenosis of the mitral valve with doming of the valve as it opens commonly accompanies the regurgitation.
Infective endocarditis affecting mitral valve
SIGNS / SYMPTOMS
Fever, chills, sweats, weight loss, Osler nodes, subungual haemorrhages, Janeway lesions, Roth spots, petechiae.
INVESTIGATIONS
Vegetations on echocardiography, typically on the atrial side of the valve. Transoesophageal echocardiogram may be more sensitive than transthoracic echocardiogram. Leukocytosis, anaemia, elevated erythrocyte sedimentation rate, microscopic haematuria may be seen.
Tricuspid valve prolapse
SIGNS / SYMPTOMS
While tricuspid prolapse may also produce a mid-systolic click sound, it is best heard at the lower left sternal border, or occasionally on the lower right parasternal area. Timing between the S1 and a tricuspid click often increases after inspiration or other manoeuvres that increase right ventricular return.
INVESTIGATIONS
Echocardiogram is diagnostic but tricuspid valve prolapse and MVP frequently co-exist, whereas isolated tricuspid valve prolapse is rare.
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