• grade one:   virtual normal leaflets, seems to correlate with "silent" prolapse. No murmur is present and click is made audible only with pharmacological maneuvers.
• grade two:  a click is present but no mitral regurgitation
• grade three:  a click is present and mild, mitral regurgitation indicated by a late systolic murmur.
• grade four:  severe prolapse with "ballooned, hooded, floppy" valves with moderate to severe regurgitation indicated by pansystolic murmur.

class 1:  no undue symptoms associated with ordinary activity and no limitations of physical activity.     class 11: slight limitation of physical activity, patient comfortable at rest.    class 111: marked limitation of physical activity, patient comfortable at rest.    class 1V: inability to carry on any physical activity without discomfort, symptoms of cardiac insufficiency or chest pain possible even at rest.     

Murmurs, and changes in murmurs can be very important clues to the doctor when checking for things such as infective endocardits.

Murmur Intensity or Loudness:

• 1.  faint, heard only with special effort

• 2.  faint but readily recognized

• 3.  prominent but not loud

• 4.  loud

• 5.  very loud

• 6.  exceptionally loud, can be heard with stethoscope removed from  the chest wall

The pitch or configuration (shape) of the murmur may change.

Shape of a murmur may by:

• crescendo - (late systolic murmur)

• decrescendo

• crescendo-decrescendo -(systolic ejection murmur)

• diamond-shaped

• plateau -(pan systolic murmur)

Auditory character of murmurs 

• rough, blowing, honking, rumbling, grunting, musical, harsh, whooping, squeaky, buzzing, scratchy.

De Robert Jeresaty outlined five stages in the progression of prolapse:

• silent prolapse

• MSC without a murmur (mid-systolic click)

• MSC and LSM         (late-systolic murmur)

• PSM    (the result of infective endocarditis, gradual deterioration and chordal rupture)(pan-systolic murmur)

• severe regurgitation, floppy valve and heart failure.

  Dr. Barlow, with an invasive test using radiographic contrast material or dye, could measure the severity of regurgitation, presence of congenital or acquired valvular legions, the pressure in the left ventricle and its motion, the volume of blood in the heart at the end of systole and diastole and the ejection factor. (percentage of blood pumped out of the ventricle)

    His findings were: 

• Pan systolic murmur: large amounts of dye entered the left atrium

• late systolic murmur: a small amount of dye was seen in the left atrium

• no murmur: no blood was forced back into the atrium.

   An Ejection Fraction is a mathematical computation which indicates how well the heart works as a pump, how much blood is put out during a cardiac cycle.  A depressed ejection fraction points to an insufficient volume of blood being ejected from the heart into the aorta and the rest of the body during a cardiac cycle.  The end result is that blood that should be pumped out remains in the ventricles and therefore the heart dilates and eventually the muscle thickens or hypertrophies from a prolonged effort to meet the oxygen demands of the body.  If blood remains in the ventricles there is a tendency for coagulation and thus the formation of thrombi.

  Normal ejection fraction is said to be around 50 percent.