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MVP Dynamic Auscultation — EECC MCQ

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EasyValvular Heart DiseaseMVP Dynamic AuscultationEECC

A 55-year-old man with mitral valve prolapse (MVP) is found to have a late systolic murmur that becomes longer and earlier with standing (Valsalva manoeuvre). What physiological principle explains this change?

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Correct answer: D — Standing/Valsalva reduces LV volume (decreased preload), causing earlier mitral leaflet prolapse in systole — the click occurs earlier and the murmur becomes longer and may be louder; squatting increases LV volume and delays/shortens the murmur

MVP dynamic auscultation is a classic physical examination teaching point: the click and late systolic murmur of MVP vary with LV volume changes. REDUCED LV volume (standing, Valsalva strain, dehydration): the mitral leaflets prolapse EARLIER in systole (smaller LV means less distance for redundant leaflets to travel before prolapsing beyond the annular plane) → click moves earlier, murmur starts earlier and becomes longer/louder. INCREASED LV volume (squatting, leg elevation, volume loading): prolapse is delayed (larger LV pushes leaflets back) → click moves later, murmur becomes shorter/softer or disappears. This is the OPPOSITE of most murmurs (VSD, AS murmurs get louder with increased preload/afterload). The 2025 ESC VHD Guidelines emphasise the importance of dynamic auscultation in clinical assessment of MVP — manoeuvres help distinguish MVP from other systolic murmurs.

Reference: ESC/EACTS (2025): VHD Guidelines