Physical Examination Findings in Mitral Valve Prolapse with Regurgitation

Primary Auscultatory Findings

The American College of Cardiology notes that a nonejection midsystolic click is the hallmark finding and represents the sudden tensing of the mitral valve apparatus as the leaflets prolapse into the left atrium during systole 1, 2
The click may occur as a single sound or as multiple clicks, and its timing moves within systole with changes in left ventricular dimensions 3
In mild-to-moderate MVP with regurgitation, expect a late systolic murmur that begins after the midsystolic click and extends to S2, as recommended by the American College of Cardiology 4, 5, 6

In severe MVP with regurgitation, a loud holosystolic murmur may be heard at the apex, though this is less common, according to the American College of Cardiology 4, 7
The murmur is best heard at the apex and may radiate to the axilla, as noted by the American College of Cardiology 7

The physical examination demonstrating very late soft systolic murmur without diastolic filling sounds indicates that regurgitation occurs only in very late systole, which is frequently overestimated by echocardiography, as stated by the American College of Cardiology 4, 5, 6

An early diastolic filling sound (S3) may be present in severe mitral regurgitation with significant volume overload, according to the American College of Cardiology 4, 7
Normal intensity and splitting of S2 is typically preserved in mild MVP, as noted by the American College of Cardiology 3

Normal left ventricular and left atrial examination findings suggest that severe chronic mitral regurgitation is unlikely, even if echocardiography suggests otherwise, as recommended by the American College of Cardiology 4, 5, 6
Signs of pulmonary congestion may be present in severe regurgitation with hemodynamic compromise, according to the American College of Cardiology 7

Standing from squatting or Valsalva maneuver decreases left ventricular volume, causing the click to occur earlier in systole and the murmur to become longer and louder, as noted by the American College of Cardiology 3
Squatting or leg raising increases left ventricular volume, causing the click to occur later in systole and the murmur to become shorter and softer, according to the American College of Cardiology 3

Failing to examine in multiple positions may miss MVP, as the physical examination in these positions is optimal for detection, as recommended by the American College of Cardiology 1, 2
Misinterpreting grade 1-2 systolic ejection murmurs at the left sternal border as MVP when they actually represent innocent flow murmurs, as noted by the American College of Cardiology 3

When physical examination suggests severe MR but echocardiography shows only mild regurgitation, the echocardiogram likely underestimates severity due to technical limitations with eccentric jets, as stated by the American College of Cardiology 8, 4
When echocardiography suggests severe MR but physical examination shows only a very late soft systolic murmur with normal chamber findings, the echocardiogram likely overestimates severity by not accounting for the short duration of late systolic regurgitation, according to the American College of Cardiology 4, 5, 6