Multiparametric Approach to Arrhythmic Mitral Valve Prolapse: Novel and Recognized Markers of Increased Sudden Cardiac Arrest Risk

Abstract

Background: Mitral valve prolapse (MVP) in some cases may predispose to life-threatening ventricular arrhythmias. The aims of this study were to evaluate determinants of arrhythmic MVP (AMVP) in a large population and to identify variables associated with sudden cardiac arrest (SCA) or sudden cardiac death.

Methods: This ambispective cohort study included patients 18 to 70 years of age with MVP with preserved ejection fraction and no coronary artery disease, cardiomyopathies, or channelopathies. AMVP was defined according to the European Heart Rhythm Association/Heart Rhythm Society consensus: MVP associated with ventricular tachycardia (VT), ≥5% of premature ventricular complexes on Holter monitoring, or SCA attributable to ventricular fibrillation or VT. All available clinical data and results of electrocardiography, echocardiography, and cardiac magnetic resonance were analyzed.

Results: The studied population comprised 574 of 3,325 patients with MVP treated between 2009 and 2024 (mean age, 38.5 ± 14.3 years; 65% women). True mitral annular disjunction (MAD) and pseudo-MAD were observed more frequently in patients with AMVP (8.0% vs 3.3% [P = .013] and 59.4% vs 24.0% [P < .001], respectively), as were "double" and "triple" e' (70.4% vs 31.3% and 43.9% vs 18.2%, respectively, P < .001). Patients with AMVP had higher values of longitudinal strain and myocardial work indices in the basal and mid segments of the left ventricular inferolateral and anterolateral walls. Independent echocardiographic variables associated with AMVP were MAD or pseudo-MAD distance, double-peak strain, "double" e' pattern, and peak strain dispersion. Peak mitral annular lateral velocity, T-wave abnormalities on electrocardiography, and VT burden on Holter monitoring were markers of malignant MVP.

Conclusions: Assessment of MAD, longitudinal strain, myocardial work, and early diastolic pattern on tissue Doppler imaging may be useful in the evaluation of arrhythmogenic MVP phenotype. The stratification of SCA or sudden cardiac death risk requires a multiparametric approach, including clinical data, results of electrocardiography, Holter monitoring, and comprehensive cardiac imaging.

Keywords: Mitral annular disjunction; Mitral valve prolapse; Sudden cardiac arrest; Sudden cardiac death; Ventricular arrhythmia.