Midsystolic Click – Mitral Valve Prolapse

The words "midsystolic click" are virtually synonymous with

prolapse of the mitral valve toward the left atrium during
systole. It is most commonly the result of myxomatous
degeneration of the valve with prolongation of the valve
and/or chordae tendinae. The central problem lies in an abnormal ratio between the length of the
mitral apparatus and the volume of the left ventricular chamber. The mitral valve is “too long”
for the size of the ventricular chamber.   

Therefore, as ventricular systole proceeds and ventricular volume declines, the valve cannot be
held in place. The valve then slips and as it is caught again to be held in place by subvalvular
tissue, the sudden cessation in motion creates a high frequency sound, the midsystolic click. 

The midsystolic click may actually occur at almost any time during systole depending upon the
length of the mitral apparatus and the volume of the left ventricle. Therefore, the time at which
the click occurs may be manipulated by a variety of maneuvers. It is this manipulation of timing
and, occasionally, precipitation of a murmur of mitral regurgitation following the click that
assures diagnosis.   

At rest, the midsystolic click is usually just that. As a result, the cadence, heard with the
diaphragm of the stethoscope, over the apical impulse, is “ta ta ta”. When such a sound is heard
and mitral prolapse suspected, the patient should be subjected to maneuvers to confirm the
diagnosis. First, the Valsalva maneuver: during the strain phase of the Valsalva maneuver,
ventricular filling is reduced and the left ventricle begins systole at a smaller volume. Therefore,
the time at which prolapse will occur moves toward the first heart sound. Additionally, as you
will hear in the recording, the different components of the mitral valve may occur at different
times giving rise to multiple clicks. In some instances, multiple clicks occurring very close
together may mimic a systolic murmur.

A maneuver that is easier to perform and examine is the squatting to standing maneuver. Upon
standing, approximately 600 ml of blood are left in the veins of the legs reducing left ventricular
volume and bringing the click nearer to the first heart sound. When resuming the squatting
position, increased afterload and augmentation of venous return increase left ventricular volume,
moving the click away from S1 toward midsystole or even later.

Other maneuvers that may be useful include handgrip (increased afterload and increased
ventricular volume) and amyl nitrate (decreased afterload and smaller ventricular volume).
Should you confirm your diagnosis by auscultation and maneuvers, do not be discouraged by a
report of a normal echocardiogram. The echo is limited by imaging windows, but with your
stethoscope, you can listen to the whole mitral valve.