Ni Made Elva Mayasari1, Dyah Wulan Anggrahini1, Hasanah Mumpuni2, Lucia Kris Dinarti2
1Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta /
Dr. Sardjito HospitSardjito General Hospital Yogyakarta al
2Echocardiography Division, Department of Cardiology and Vascular Medicine, Faculty of Medicine,
Universitas Gadjah Mada / Sardjito General Hospital Yogyakarta
Abstract
Background: Association between secundum atrial septal defect (ASD) and mitral valve disease
has been recognized for many years. Noninvasive studies indicate a high incidence of mitral valve
prolapse (37-70 percent) in these patients. Change of left ventricular geometry in atrial septal defect
had been showed were associated with degree of mitral valve prolapse. This study delineates the
incidence of mitral valve prolaps and mitral regurgitation in adult patients with secundum atrial
septal defect and association with age at onset and size defect.
Method: This study was a substudy from ASD registry in Dr. Sardjito General Hospital. The records
of 103 adult patients ranged in age from 17 to 76 years old, with an average of 36 years old, and
consisted of 16 men and 87 women who had secundum atrial septal defects demonstrated by cross
sectional echocardiography between july 2012 until july 2013. Echocardiographic examinations
were performed with the patient in the supine position. The echocardiograph was a Vivid 7. The
mitral valve apparatus and mitral regurgitation was examined with long axis images, short axis
image and apical four chamber view.
Result: Mitral valve prolapse was observed in 76% patients with secundum atrial septal defect.
Prolaps of anterior mitral leafl et (AML) in age group younger than 35 years and older than 36 years
are 38,6% and 61,4% respectively. The incidence of mitral regurgitation was 43%. Severity variance
of mitral regurgitation were 31,7% mild, 7,7% moderate and 2,9% severe. Mitral regurgitation in
patient with prolapse AML was 56.4%. None of the patients without mitral valve prolapse had mitral
regurgitation.In patient with size defect more than 2 cm, the proportion of prolapse of AML and
mitral regurgitation was higher as compared with patient with size defect less than 2 cm.
Conclusion: Incidence of mitral valve prolaps and mitral regurgitation are high in patient with atrial
septal defect and increase with onset of age. Patients with larger size defect had a greater likelihood
of mitral prolapse and mitral regurgitation. Onset of age and size defect might be associated with
magnitude of the shunt and abnormal ventricular geometry.
Keyword: Secundum atrial septal defect, mitral valve prolaps, mitral regurgitation
Introduction
Atrial septal defect (ASD) is the most
common congenital heart disease encountered in
adult population. This defect result in shunt from
left to the right of the heart which consequence
of volume overload in right heart. The volume
overload infl uences the position and the size of
interventricular septum.1 The association between
secundum ASD and deformity in mitral valve has
been recognized. Several studies show high
prevalence of mitral valve prolaps, approximately
37% - 70% . Mitral valve prolaps relate with mitral
regurgitation. In ASD patients, the incidence of
clinically signifi cant mitral regurgitation is rare as
compared to mitral valve prolaps.2 The prevalence
of mitral regurgitation is less than 10% of adult
patients with large secundum ASD.3
The cause of mitral regurgitation associated
with secundum ASD can be classified into
extrinsic and intrinsic factors. Extrinsic factor
is associated with rheumatic valve disease or
infective endocarditis, whereas the intrinsic factor
is related with ASD itself which cause mitral valve
regurgitation.4
The deformity of mitral valve is associated
with the change of ventricular geometry in patient
with ASD. Chronic dilatation of right ventricle due to
volume overload result in enlargement from basal
into apical dimension as well as from lateral into
septal dimension of right ventricle. It result in the
displacement of right ventricular apex to the left replacing the apex of left ventricle as true apex of
the heart. This ventricular dilatation is infl uenced
by the fl ow from left to right. The aim of this study is
to investigate the incidence of mitral valve prolaps
and regurgitation in patients with ASD and analyse
the impact of age and the size of defect on mitral
valve prolaps and regurgitation.
Method
The study is a cross sectional study. This
study is a sub study from the ASD-PH registry in Dr.
Sardjito Hospital which is conducted since 2012.
The time of this study is from July 2012 until July
2013. The subjects are 103 patients registered
in the registry. All subjects are examined with
transthoracal echocardiography (TEE) by Vivid 7
echo machine with standard technique and view.
The defect size, the presence of mitral valve
prolaps and mitral regurgitation are documented.
The age group is assigned with cut-off point of 35
years. The size of defect is assigned with cut-off
point of 2 cm.
The statistics analysis is performed to
compared variables between groups. The incidence
of mitral valve prolaps and mitral regurgitation is
shown in percentage. Patients age and size of
defect are presented as categorical variable based
on cut-off point. Descriptive analysis is performed
to compare and associate between mitral valve
prolaps and mitral regurgitation with age and size
of defect.
Result
The subjects of this study range from 17
years old to 76 years old with mean age is 36
years. It consists of 16 males and 87 females. The
mean size of defects is 2.5 cm. Anterior mitral valve
prolaps is observed in 76% and mitral regurgitation
in 43%. The mitral regurgitation occurs in 56.4%
in patients with mitral valve prolaps, In this study,
none of the subjects has mitral regurgitation alone
without mitral valve prolaps.
In subjects with the size of defects ≥ 2 cm,
the incidence of mitral valve prolaps and mitral
regurgitation is higher as compared to those with
the size of defetcs < 2 cm. The incidence of mitral
valve prolaps is 78.2% and mitral regurgitation
is 79.5% in subjects with defect ≥ 2 cm, in the
latter the mitral valve prolaps incidence is 20.5%
and mitral regurgitation is 20.5%. The proportion
between two subject groups is shown in fi gure 1
and 2.
Figure 1. Incidence of mitral valve prolaps based
on ASD defect size
Figure 2. Incidence of mitral regurgitation based
on ASD defect size
In subjects with age ≥ 36 years old, the
proportion of mitral valve prolaps and mitral
regurgitation is higher as compared with subjects ≤
35 years old. The incidence of mitral valve prolaps
is 79.2% and mitral regurgitation is 61.4% in
subjects ≥ 36 years of age. Whereas, the incidence
of mitral valve prolaps in subjects ≤ 35 years old
is 72.7% and mitral regurgitation is 38.6%. The
proportion between two subject groups is shown
in fi gure 3 and 4.
Figure 3. Incidence of mitral valve prolaps based
on age Figure 4. Incidence of mitral regurgitation based
on age
Discussion
The incidence of mitral valve prolaps in
general population based on echocardiography
examination is approximately 5%. Mitral
regurgitation associated with mitral valve prolaps
occurs in around 0.01%-0.02%. Several heart
defects associated with mitral valve prolaps, such
as secundum ASD.5 Several studies reported high
incidence of mitral valve prolaps accompanied
ASD, which was 37-70%. This mitral valve prolaps
also associated with mitral regurgitation.2 None
of the patients in the study showed lone mitral
regurgitation without mitral valve prolaps.
Previous study shows ASD patients with
mitral valve prolaps have smaller left ventricular
volume, larger size of defect and older ages .3
Mitral regurgitation seemed to be associated
with increasing age.2 Mitral valve prolaps occurs
signifi cantly higher in patients with age more than
35 years old than those younger and very rarely in
children. 6 Our study shows the incidence of mitral
valve prolaps and mitral regurgitation is higher in
subjects with ≥ 36 years of age and have larger
size of defects.
The etiology of mitral regurgitation
associated with secundum ASD can be classifi ed
into two categories, i.e. extrinsic and intrinsic
factors. Extrinsic factors associated with rheumatic
valve disease and infective endocarditis. Intrinsic
factor is caused by ASD itself which result in mitral
regurgitation4. There are two hypothesis related
to high incidence of mitral valve prolaps in ASD.
Firstly, the prolaps is a manifestation of anatomic
changes due to congenital defect in fi brous tissue.
Secondly, the prolaps is acquisital changes due
to left ventricle geometry changes. The closure of
ASD defect may cause the changes of left ventricle
geometry which is shown by signifi cant reduction
of right ventricle volume and rapid increase in left
ventricle volume.7 The changes in left ventricle
geometry is associated with the reduction of mitral
valve prolaps degree.7 The ASD closure causes
improvement in mitral valve prolaps and reduction
of mitral regurgittion degree in the majority of
patients.3 In this study, the incidence of mitral
valve prolaps and mitral regurgitation is higher in
patients with larger defect size. This is associated
with the higher fl ow of shunt which can infl uence
the changes in ventricle geometry.
Conclusion
The incidence of mitral valve prolaps and
mitral regurgitation is high in secundum ASD. Mitral
regurgitation in ASD is associated with mitral valve
prolaps. The incidence is increasing with increased
age and larger defect. The age and defect size
affects mitral valve pathology may be due to higher
fl ow and the changes in ventricle geometry.
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