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Esposito A, Gatti M, Trivieri MG, Agricola E, Peretto G, Gallone G, Catapano F, Pradella S, Devesa A, Bruno E, Fiore G, Francone M, Palmisano A. Imaging for the assessment of the arrhythmogenic potential of mitral valve prolapse. Eur Radiol 2024; 34:4243-4260. [PMID: 38078997 PMCID: PMC11164824 DOI: 10.1007/s00330-023-10413-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/04/2023] [Accepted: 10/09/2023] [Indexed: 05/18/2024]
Abstract
Mitral valve prolapse (MVP) is the most common valve disease in the western world and recently emerged as a possible substrate for sudden cardiac death (SCD). It is estimated an annual risk of sudden cardiac death of 0.2 to 1.9% mostly caused by complex ventricular arrhythmias (VA). Several mechanisms have been recognized as potentially responsible for arrhythmia onset in MVP, resulting from the combination of morpho-functional abnormality of the mitral valve, structural substrates (regional myocardial hypertrophy, fibrosis, Purkinje fibers activity, inflammation), and mechanical stretch. Echocardiography plays a central role in MVP diagnosis and assessment of severity of regurgitation. Several abnormalities detectable by echocardiography can be prognostic for the occurrence of VA, from morphological alteration including leaflet redundancy and thickness, mitral annular dilatation, and mitral annulus disjunction (MAD), to motion abnormalities detectable with "Pickelhaube" sign. Additionally, speckle-tracking echocardiography may identify MVP patients at higher risk for VA by detection of increased mechanical dispersion. On the other hand, cardiac magnetic resonance (CMR) has the capability to provide a comprehensive risk stratification combining the identification of morphological and motion alteration with the detection of myocardial replacement and interstitial fibrosis, making CMR an ideal method for arrhythmia risk stratification in patients with MVP. Finally, recent studies have suggested a potential role in risk stratification of new techniques such as hybrid PET-MR and late contrast enhancement CT. The purpose of this review is to provide an overview of the mitral valve prolapse syndrome with a focus on the role of imaging in arrhythmic risk stratification. CLINICAL RELEVANCE STATEMENT: Mitral valve prolapse is the most frequent valve condition potentially associated with arrhythmias. Imaging has a central role in the identification of anatomical, functional, mechanical, and structural alterations potentially associated with a higher risk of developing complex ventricular arrhythmia and sudden cardiac death. KEY POINTS: • Mitral valve prolapse is a common valve disease potentially associated with complex ventricular arrhythmia and sudden cardiac death. • The mechanism of arrhythmogenesis in mitral valve prolapse is complex and multifactorial, due to the interplay among multiple conditions including valve morphological alteration, mechanical stretch, myocardial structure remodeling with fibrosis, and inflammation. • Cardiac imaging, especially echocardiography and cardiac magnetic resonance, is crucial in the identification of several features associated with the potential risk of serious cardiac events. In particular, cardiac magnetic resonance has the advantage of being able to detect myocardial fibrosis which is currently the strongest prognosticator.
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Affiliation(s)
- Antonio Esposito
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy.
| | - Marco Gatti
- Radiology Unit, Department of Surgical Sciences, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Maria Giovanna Trivieri
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eustachio Agricola
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Peretto
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Città Della Salute E Della Scienza, University of Turin, Turin, Italy
| | - Federica Catapano
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Silvia Pradella
- Department of Emergency Radiology, University Hospital Careggi, Florence, Italy
| | - Ana Devesa
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Elisa Bruno
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
| | - Giorgio Fiore
- Cardiovascular Imaging Unit, Cardiothoracic Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Francone
- IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Anna Palmisano
- Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Università Vita-Salute San Raffaele, Milan, Italy
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2
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Maines M, Rotondi F, Guarracini F, Esposito C, Peruzza F, Vitillo P, Kola N, Quintarelli S, Franculli F, Napoli P, Giacopelli D, Del Greco M, Di Lorenzo E, Marini M. Incidental and anticipated arrhythmic diagnoses in patients with an implantable cardiac monitor. J Cardiovasc Med (Hagerstown) 2024; 25:429-437. [PMID: 38625830 DOI: 10.2459/jcm.0000000000001624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2024]
Abstract
AIMS In this study, we investigated a cohort of unselected patients with various indications for an implantable cardiac monitor (ICM). Our main objectives were to determine the incidence of arrhythmic diagnoses, both anticipated and incidental in relation to the ICM indication, and to assess their clinical relevance. METHODS We examined remote monitoring transmissions from patients with an ICM at four Italian sites to identify occurrences of cardiac arrhythmias. Concurrently, we collected data on medical actions taken in response to arrhythmic findings. RESULTS The study included 119 patients, with a median follow-up period of 371 days. ICM indications were syncope/presyncope (46.2%), atrial fibrillation management (31.1%), and cryptogenic stroke (22.7%). In the atrial fibrillation management group, atrial fibrillation was the most common finding, with an incidence of 36% [95% confidence interval (CI) 22-55%] at 18 months. Rates of atrial fibrillation were not significantly different between patients with cryptogenic stroke and syncope/presyncope [17% (95% CI 7-40%) vs. 8% (95% CI 3-19%), P = 0.229].For patients with cryptogenic stroke, the incidence of asystole and bradyarrhythmias at 18 months was 23% (95% CI 11-45%) and 42% (95% CI 24-65%), respectively, similar to estimates obtained for patients implanted for syncope/presyncope ( P = 0.277 vs. P = 0.836).Overall, 30 patients (25.2%) required medical intervention following ICM-detected arrhythmias, predominantly involving atrial fibrillation ablation (10.9%) and medication therapy changes (10.1%). CONCLUSION In a real-life population with heterogeneous insertion indications, approximately 25% of patients received ICM-guided medical interventions within a short timeframe, including treatments for incidental findings. Common incidental arrhythmic diagnoses were bradyarrhythmias in patients with cryptogenic stroke and atrial fibrillation in patients with unexplained syncope.
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Affiliation(s)
| | | | | | - Cristina Esposito
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | - Francesco Peruzza
- Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto
| | | | - Nertil Kola
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | | | - Fabio Franculli
- Division of Cardiology, OO.RR. San Giovanni di Dio Ruggi d'Aragona, 84131 Salerno (SA)
| | - Paola Napoli
- Clinical Unit, Biotronik Italia S.p.a, Cologno Monzese (MI), Italy
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3
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Haugaa KH, Aabel EW. Cardiac arrest, mitral annular disjunction, and mitral valve prolapse: where there is smoke, there is a fire. Eur Heart J Cardiovasc Imaging 2024; 25:771-773. [PMID: 38546703 PMCID: PMC11139509 DOI: 10.1093/ehjci/jeae079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Affiliation(s)
- Kristina H Haugaa
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Problemveien 11, 0313 Oslo, Norway
| | - Eivind W Aabel
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Sognsvannsveien 20, 0372 Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Problemveien 11, 0313 Oslo, Norway
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4
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Blondeel M, L’Hoyes W, Robyns T, Verbrugghe P, De Meester P, Dresselaers T, Masci PG, Willems R, Bogaert J, Vandenberk B. Serial Cardiac Magnetic Resonance Imaging in Patients with Mitral Valve Prolapse-A Single-Center Retrospective Registry. J Clin Med 2024; 13:2669. [PMID: 38731198 PMCID: PMC11084857 DOI: 10.3390/jcm13092669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Mitral valve prolapse (MVP) and mitral annular disjunction (MAD) are common valvular abnormalities that have been associated with ventricular arrhythmias (VA). Cardiac magnetic resonance imaging (CMR) has a key role in risk stratification of VA, including assessment of late gadolinium enhancement (LGE). Methods: Single-center retrospective analysis of patients with MVP or MAD who had >1 CMR and >1 24 h Holter registration available. Data are presented in detail, including evolution of VA and presence of LGE over time. Results: A total of twelve patients had repeated CMR and Holter registrations available, of which in four (33%) patients, it was conducted before and after minimal invasive mitral valve repair (MVR). After a median of 4.7 years, four out of eight (50%) patients without surgical intervention had new areas of LGE. New LGE was observed in the papillary muscles and the mid to basal inferolateral wall. In four patients, presenting with syncope or high-risk non-sustained ventricular tachycardia (VT), programmed ventricular stimulation was performed and in two (50%), sustained monomorphic VT was easily inducible. In two patients who underwent MVR, new LGE was observed in the basal inferolateral wall of which one presented with an increased burden of VA. Conclusions: In patients with MVP and MAD, repeat CMR may show new LGE in a small subset of patients, even shortly after MVR. A subgroup of patients who presented with an increase in VA burden showed new LGE upon repeat CMR. VA in patients with MVP and MAD are part of a heterogeneous spectrum that requires further investigation to establish risk stratification strategies.
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Affiliation(s)
- Maarten Blondeel
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Wouter L’Hoyes
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Tomas Robyns
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Peter Verbrugghe
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Pieter De Meester
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Tom Dresselaers
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King’s College London, St Thomas Hospital, London SE1 7EH, UK
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Imaging and Pathology, KU Leuven, 3000 Leuven, Belgium
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, 3000 Leuven, Belgium
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5
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Dziadosz D, Daniłowicz-Szymanowicz L, Wejner-Mik P, Budnik M, Brzezińska B, Duchnowski P, Golińska-Grzybała K, Jaworski K, Jedliński I, Kamela M, Kasprzak J, Kowalczyk-Domagała M, Kurnicka K, Kustrzycka-Kratochwil D, Mickiewicz K, Możeńska O, Oko-Sarnowska Z, Plewka M, Polewczyk A, Uziębło-Życzkowska B, Wierzbowska-Drabik K, Wachnicka-Truty R, Wołoszyn-Horák E, Szymański P, Gackowski A, Mizia-Stec K. What Do We Know So Far About Ventricular Arrhythmias and Sudden Cardiac Death Prediction in the Mitral Valve Prolapse Population? Could Biomarkers Help Us Predict Their Occurrence? Curr Cardiol Rep 2024; 26:245-268. [PMID: 38507154 PMCID: PMC11136782 DOI: 10.1007/s11886-024-02030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE OF THE REVIEW To summarize currently available data on the topic of mitral valve prolapse (MVP) and its correlation to the occurrence of atrial and ventricular arrhythmias. To assess the prognostic value of several diagnostic methods such as transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance, cardiac computed tomography, electrocardiography, and electrophysiology concerning arrhythmic episodes. To explore intra and extracellular biochemistry of the cardiovascular system and its biomarkers as diagnostic tools to predict rhythm disturbances in the MVP population. RECENT FINDINGS MVP is a common and mainly benign valvular disorder. It affects 2-3% of the general population. MVP is a heterogeneous and highly variable phenomenon with three structural phenotypes: myxomatous degeneration, fibroelastic deficiency, and forme fruste. Exercise intolerance, supraventricular tachycardia, and chest discomfort are the symptoms that are often paired with psychosomatic components. Though MVP is thought to be benign, the association between isolated MVP without mitral regurgitation (MR) or left ventricle dysfunction, with ventricular arrhythmia (VA) and sudden cardiac death (SCD) has been observed. The incidence of SCD in the MVP population is around 0.6% per year, which is 6 times higher than the occurrence of SCD in the general population. Often asymptomatic MVP population poses a challenge to screen for VA and prevent SCD. Therefore, it is crucial to carefully assess the risk of VA and SCD in patients with MVP with the use of various tools such as diagnostic imaging and biochemical and genetic screening.
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Affiliation(s)
- D Dziadosz
- 1st Department of Cardiology, Faculty of Medicine, Medical University of Silesia, Katowice, Poland
- Centre of European Reference Network of Heart Diseases - ERN GUARD-HEART, 47 Ziołowa St, 40-635, Katowice, Poland
| | - L Daniłowicz-Szymanowicz
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - P Wejner-Mik
- 1st Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Łódź, Poland
| | - M Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Central Clinical Hospital, 1a Banacha St, 02-97, Warsaw, Poland
| | - B Brzezińska
- Department of Cardiology, T. Marciniak Hospital, Wrocław, Poland
| | - P Duchnowski
- Cardinal Wyszynski National Institute of Cardiology, 04-628, Warsaw, Poland
| | - K Golińska-Grzybała
- Dept of Coronary Disease and Heart Failure, Noninvasive Cardiovascular Laboratory, Medical College, Jagiellonian University, St. John Paul II Hospital, Cracow, Poland
| | - K Jaworski
- Department of Coronary Artery Disease and Cardiac Rehabilitation, National Institute of Cardiology, Warsaw, Poland
| | - I Jedliński
- Medicor, Powstańców Wielkopolskich 4, 61-895, Poznań, Poland
| | - M Kamela
- Department of Cardiology, Hospital of the Ministry of Interior and Administration, Rzeszów, Poland
| | - J Kasprzak
- 1st Department of Cardiology, Medical University of Lodz, Bieganski Hospital, Łódź, Poland
| | - M Kowalczyk-Domagała
- Pediatric Cardiology Department, The Children's Memorial Health Institute, Warsaw, Poland
| | - K Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Infant Jesus Clinical Hospital, Lindleya str. 4, 02-005, Warsaw, Poland
| | - D Kustrzycka-Kratochwil
- Department of Cardiology, Center for Heart Diseases, 4th Military Clinical Hospital, Weigla 5, 50-981, Wrocław, Poland
| | - K Mickiewicz
- Department of Cardiology, Medical University of Bialystok, 15-276, Białystok, Poland
| | - O Możeńska
- JO Medical Center, Quo Vadis 1/U6, 02-495, Warsaw, Poland
| | - Z Oko-Sarnowska
- Department of Cardiology, Poznań University of Medical Sciences, Wielkopolskie, 60-355, Poznań, Poland
| | - M Plewka
- Department of Interventional Cardiology and Cardiac Arrhythmias, Military Medical Academy Memorial Teaching Hospital of the Medical University of Lodz, Łódź, Poland
| | - A Polewczyk
- Department of Physiology, Pathophysiology and Clinical Immunology, Institute of Medical Sciences, Jan Kochanowski University, Żeromskiego 5, 25-369, Kielce, Poland
- Department of Cardiac Surgery, Świętokrzyskie Cardiology Center, Grunwaldzka 45, 25-736, Kielce, Poland
| | - B Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine - National Research Institute, Warsaw, Poland
| | - K Wierzbowska-Drabik
- Department of Internal Medicine and Clinical Pharmacology, Medical University of Lodz, Łódź, Poland
| | - R Wachnicka-Truty
- Department of Cardiology and Internal Diseases, Institute of Maritime and Tropical Medicine, Medical University of Gdańsk, Gdynia, Poland
| | - E Wołoszyn-Horák
- Second Department of Cardiology. Specialist Hospital in Zabrze, Medical University of Silesia, Curie-Sklodowskiej str. 10, Zabrze, Poland
| | - P Szymański
- Center of Clinical Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - A Gackowski
- Dept of Coronary Disease and Heart Failure, Noninvasive Cardiovascular Laboratory, Medical College, Jagiellonian University, St. John Paul II Hospital, Cracow, Poland
| | - K Mizia-Stec
- 1st Department of Cardiology, Faculty of Medicine, Medical University of Silesia, Katowice, Poland.
- Centre of European Reference Network of Heart Diseases - ERN GUARD-HEART, 47 Ziołowa St, 40-635, Katowice, Poland.
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6
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Five CK, Hasselberg NE, Chivulescu M, Rootwelt-Norberg C, Ribe MP, Dejgaard LA, Castrini AI, Aabel EW, Haugaa KH. Prediction of severe ventricular arrhythmias in patients with mitral valve prolapse by exercise ECG. Heart Rhythm 2024:S1547-5271(24)02503-7. [PMID: 38663787 DOI: 10.1016/j.hrthm.2024.04.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 04/15/2024] [Accepted: 04/18/2024] [Indexed: 05/15/2024]
Affiliation(s)
- Christian K Five
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Nina E Hasselberg
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Monica Chivulescu
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
| | - Christine Rootwelt-Norberg
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Margareth P Ribe
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Lars A Dejgaard
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anna I Castrini
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Eivind W Aabel
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristina H Haugaa
- Department of Cardiology, ProCardio Center for Innovation, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
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7
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Van der Bijl P, Stassen J, Haugaa KH, Essayagh B, Basso C, Thiene G, Faletra FF, Edvardsen T, Enriquez-Sarano M, Nihoyannopoulos P, Ajmone Marsan N, Chandrashekhar YS, Bax JJ. Mitral Annular Disjunction in the Context of Mitral Valve Prolapse: Identifying the At-Risk Patient. JACC Cardiovasc Imaging 2024:S1936-878X(24)00119-0. [PMID: 38703174 DOI: 10.1016/j.jcmg.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 05/06/2024]
Abstract
Mitral annular disjunction (MAD), a separation between the left atrium/mitral valve annulus and the left ventricular myocardium, is frequently seen in patients with arrhythmic mitral valve prolapse. Although an association exists between MAD and ventricular arrhythmias, little is known regarding the identification of individuals at high risk. Multimodality imaging including echocardiography, computed tomography, cardiac magnetic resonance, and positron emission tomography can play an important role in both the diagnosis and risk stratification of MAD. Due to a paucity of data, clinical decision making in a patient with MAD is challenging and remains largely empirical. Although MAD itself can be corrected surgically, the prevention and treatment of associated arrhythmias may require medical therapy, catheter ablation, and an implantable cardioverter-defibrillator. Prospective data are required to define the role of implantable cardioverter-defibrillators, targeted catheter ablation, and surgical correction in selected, at-risk patients.
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Affiliation(s)
- Pieter Van der Bijl
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jan Stassen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands; Department of Cardiology, Jessa Hospital, Hasselt, Belgium
| | - Kristina H Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway; Faculty of Medicine, Huddinge, Karolinska Institute and Cardiovascular Division, Karolinska University Hospital, Stockholm, Sweden
| | - Benjamin Essayagh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; Department of Echocardiography, CardioXClinic, Cannes, France
| | - Cristina Basso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Gaetano Thiene
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway
| | | | | | - Nina Ajmone Marsan
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands.
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8
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Perazzolo Marra M, Cecere A, Cipriani A, Migliore F, Zorzi A, De Lazzari M, Lorenzoni G, Cecchetto A, Brunetti G, Graziano F, Pittorru R, Motta R, De Conti G, Bauce B, Corrado D, Gregori D, Iliceto S. Determinants of Ventricular Arrhythmias in Mitral Valve Prolapse. JACC Clin Electrophysiol 2024; 10:670-681. [PMID: 38340116 DOI: 10.1016/j.jacep.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/04/2023] [Accepted: 12/04/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Mitral valve prolapse (MVP) may be associated with ventricular arrhythmias (VA) even in the absence of significant valvular regurgitation. Curling, mitral annulus disjunction (MAD) and myocardial fibrosis (late gadolinium enhancement [LGE]) may account for arrhythmogenesis. OBJECTIVES This study investigated the determinants of VA in patients with MVP without significant regurgitation. METHODS This study included 108 patients with MVP (66 female; median age: 48 years) without valve regurgitation. All patients underwent 12-lead electrocardiography, 12-lead 24-hour electrocardiographic Holter monitoring, exercise stress test, and cardiac magnetic resonance. Patients were divided into 2 groups (arrhythmic and no-arrhythmic MVP), according to the presence of VA with a right bundle branch block pattern. RESULTS The 62 patients (57%) with arrhythmic MVP showed: 1) higher MAD (median length: 6.0 vs 3.2 mm; P = 0.017); 2) higher prevalence of curling (79% vs 52%; P = 0.012); and 3) higher prevalence of left ventricular LGE (79% vs 52%; P = 0.012). Mediation analysis showed that curling had both a direct (P = 0.03) and indirect effect mediated by LGE (P = 0.04) on VA, whereas the association between MAD and VA was completely mediated by LGE. Patients with severe VA showed more pronounced morphofunctional alterations, in terms of MAD (7.0 vs 4.6 mm; P = 0.004) and presence and severity of curling (respectively, 91% vs 64%; P = 0.010; and 4 vs 3 mm; P = 0.004), compared to those without severe VA. CONCLUSIONS In patients with MVP the occurrence of VA with right bundle branch block morphology is the expression of more severe morphologic, mechanical, and tissue alterations. Curling has both a direct and an indirect effect on VA.
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Affiliation(s)
- Martina Perazzolo Marra
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy.
| | - Annagrazia Cecere
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Federico Migliore
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Manuel De Lazzari
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Antonella Cecchetto
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulia Brunetti
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Francesca Graziano
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Raimondo Pittorru
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Raffaella Motta
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Giorgio De Conti
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Barbara Bauce
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Domenico Corrado
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Dario Gregori
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, University of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padua, Padua, Italy
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9
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Compagnucci P, Selimi A, Cipolletta L, Volpato G, Gasperetti A, Valeri Y, Parisi Q, Curcio A, Natale A, Dello Russo A, Casella M. Arrhythmic Mitral Valve Prolapse and Sports Activity: Pathophysiology, Risk Stratification, and Sports Eligibility Assessment. J Clin Med 2024; 13:1350. [PMID: 38592178 PMCID: PMC10932446 DOI: 10.3390/jcm13051350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 04/10/2024] Open
Abstract
Although mitral valve prolapse (MVP) is the most prevalent valvular abnormality in Western countries and generally carries a good prognosis, a small subset of patients is exposed to a significant risk of malignant ventricular arrhythmias (VAs) and sudden cardiac death (SCD), the so-called arrhythmic MVP (AMVP) syndrome. Recent work has emphasized phenotypical risk features of severe AMVP and clarified its pathophysiology. However, the appropriate assessment and risk stratification of patients with suspected AMVP remains a clinical conundrum, with the possibility of both overestimating and underestimating the risk of malignant VAs, with the inappropriate use of advanced imaging and invasive electrophysiology study on one hand, and the catastrophic occurrence of SCD on the other. Furthermore, the sports eligibility assessment of athletes with AMVP remains ill defined, especially in the grey zone of intermediate arrhythmic risk. The definition, epidemiology, pathophysiology, risk stratification, and treatment of AMVP are covered in the present review. Considering recent guidelines and expert consensus statements, we propose a comprehensive pathway to facilitate appropriate counseling concerning the practice of competitive/leisure-time sports, envisioning shared decision making and the multidisciplinary "sports heart team" evaluation of borderline cases. Our final aim is to encourage an active lifestyle without compromising patients' safety.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Adelina Selimi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
- Department of Cardiology, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Quintino Parisi
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
| | - Antonio Curcio
- Division of Cardiology, Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, 87036 Rende, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David’s Medical Center, Austin, TX 78705, USA;
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA 92037, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH 44195, USA
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, 60121 Ancona, Italy;
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, Marche University Hospital, 60126 Ancona, Italy; (A.S.); (L.C.); (G.V.); (Y.V.); (Q.P.); (A.D.R.)
- Department of Medical, Special and Dental Sciences, Marche Polytechnic University, 60121 Ancona, Italy
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10
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Cecere A, Cipriani A, De Lazzari M, Graziano F, Brunetti G, De Conti G, Motta R, Ravagnin A, Lorenzoni G, Gregori D, Basso C, Tona F, Lee YJ, Delling FN, Iliceto S, Marra MP. Left ventricular fibrosis in arrhythmic mitral valve prolapse: quantification and comparison of semi-automated techniques assessed by cardiac magnetic resonance. Int J Cardiovasc Imaging 2024; 40:275-285. [PMID: 38141098 PMCID: PMC10884156 DOI: 10.1007/s10554-023-03006-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 11/03/2023] [Indexed: 12/24/2023]
Abstract
PURPOSE Left ventricular (LV) fibrosis has a key role in arrhythmogenesis in patients with mitral valve prolapse (MVP). Cardiac magnetic resonance identifies LV fibrosis by using late gadolinium enhancement (LGE) technique. LGE assessment and quantification in patients with MVP lacks of standardization protocols. METHODS 66 MVP patients with normal systolic function and without significant regurgitation were enrolled. Semi-automated gray-scale thresholding techniques using full width at half maximum (FWHM) and 2, 3 and 5 standard deviation (SD) above the remote myocardium were used and compared with the visual assessment, considered as the gold standard. RESULTS LGE was identified in 41 MVP patients (62%) and quantified. The mean quantity of LGE visually assessed was 2.40 ± 1.07% or 1.40 ± 0.82 g. With FWHM, LGE resulted 3.56 ± 1.23% or 1.99 ± 1.13 g. Using thresholding, the mean LGE quantity was 9.2 ± 3.1% or 4.82 ± 2.28 g for 2-SD, 5.72 ± 1.75% or 3.06 ± 1.47 g for 3-SD and 2.36 ± 0.99% or 1.29 ± 0.79 g for 5-SD. The 5-SD measurement in percentage demonstrated a good correlation with LGE quantification visually assessed (2.40 ± 1.07 vs. 2.363 ± 0.9909, p = 0.543). When compared with the gold standard, the 5-SD threshold quantification, both in percentage and in grams, revealed the least intra-observer (respectively, ICC: 0.976 and 0.966) and inter-observer variability (respectively ICC: 0.948 and 0.935). CONCLUSION The 5-SD gray-scale threshold technique in percentage revealed the best correlation with the visual assessment and an optimal reproducibility in MVP patient.
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Affiliation(s)
- Annagrazia Cecere
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Alberto Cipriani
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Manuel De Lazzari
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Francesca Graziano
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giulia Brunetti
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giorgio De Conti
- Radiology Unit, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Raffaella Motta
- Department of Medicine, University of Padua-Azienda Ospedaliera, Padua, Italy
| | - Alberto Ravagnin
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Dario Gregori
- Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Unit of Biostatistics, Epidemiology and Public Health, University of Padova, Padova, Italy
| | - Cristina Basso
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Francesco Tona
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Yoo Jin Lee
- Clinical Radiology, Cardiac and Pulmonary Imaging, University of California, San Francisco, CA, USA
| | - Francesca Nesta Delling
- Department of Medicine (Cardiovascular Division), University of California San Francisco, San Francisco, CA, USA
| | - Sabino Iliceto
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy
| | - Martina Perazzolo Marra
- Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua-Azienda Ospedaliera, Via Giustiniani, 2, 35128, Padua, Italy.
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11
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L'Hoyes W, Robyns T, Moura-Fereira S, De Meester P, Dresselaers T, Herregods MC, Rega F, Masci PG, Willems R, Bogaert J, Vandenberk B. Effectiveness of the risk stratification proposed by the 2022 European Heart Rhythm Association Expert Consensus statement on arrhythmic mitral valve prolapse. Am Heart J 2023; 266:48-60. [PMID: 37595658 DOI: 10.1016/j.ahj.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/04/2023] [Accepted: 08/13/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Recently, an expert consensus statement proposed indications where implantation of a primary prevention implantable cardioverter-defibrillator (ICD) may be reasonable in patients with mitral valve prolapse (MVP). The objective was to evaluate the proposed risk stratification by the expert consensus statement. METHODS Consecutive patients with MVP without alternative arrhythmic substrates with cardiac magnetic resonance imaging (CMR) were included in a single-center retrospective registry. Arrhythmic MVP (AMVP) was defined as a total premature ventricular complex burden ≥5%, non-sustained ventricular tachycardia (VT), VT, or ventricular fibrillation. The end point was a composite of SCD, VT, inducible VT, and appropriate ICD shocks. RESULTS In total, 169 patients (52.1% male, median age 51.4 years) were included and 99 (58.6%) were classified as AMVP. Multivariate logistic regression identified the presence of late gadolinium enhancement (OR 2.82, 95%CI 1.45-5.50) and mitral annular disjunction (OR 1.98, 95%CI 1.02-3.86) as only predictors of AMVP. According to the EHRA risk stratification, 5 patients with AMVP (5.1%) had a secondary prevention ICD indication, while in 69 patients (69.7%) the implantation of an ICD may be reasonable. During a median follow-up of 8.0 years (IQR 5.0-15.6), the incidence rate for the composite arrhythmic end point was 0.3%/year (95%CI 0.1-0.8). CONCLUSION More than half of MVP patients referred for CMR met the AMVP diagnostic criteria. Despite low long-term event rates, in 70% of patients with AMVP the implantation of an ICD may be reasonable. Risk stratification of SCD in MVP remains an important knowledge gap and requires urgent investigation.
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Affiliation(s)
- Wouter L'Hoyes
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Tomas Robyns
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Sara Moura-Fereira
- Department of Cardiology, Hartcentrum, Jessa Hospital, Hasselt, Belgium; Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Pieter De Meester
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Tom Dresselaers
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Marie-Christine Herregods
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pier Giorgio Masci
- School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas Hospital, London, United Kingdom
| | - Rik Willems
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Jan Bogaert
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium; Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
| | - Bert Vandenberk
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium; Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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12
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Benjanuwattra J, Kewcharoen J, Phinyo P, Swusdinaruenart S, Abdelnabi M, Del Rio-Pertuz G, Leelaviwat N, Navaravong L. High-risk phenotypes of arrhythmic mitral valve prolapse: a systematic review and meta-analysis. Acta Cardiol 2023; 78:1012-1019. [PMID: 37358248 DOI: 10.1080/00015385.2023.2227487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/01/2023] [Accepted: 06/11/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Mitral valve prolapse (MVP) is associated with aggravated risk of ventricular tachycardia (VT), ventricular fibrillation (VF) and sudden cardiac death (SCD). There is a lack of specific guideline recommendation regarding risk stratification and management, despite multiple proposed high-risk phenotypes. We performed systematic review and meta-analysis to evaluate high-risk phenotypes for malignant arrhythmias in patients with MVP. METHODS We comprehensively searched the databases of MEDLINE, SCOPUS, and EMBASE from inception to April 2023. Included studies were cohort and case-control comparing between MVP patients with and without VT, VF, cardiac arrest, ICD placement, or SCD. Data from each study were combined using the random-effects. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS Nine studies from 1985 to 2023 were included involving 2,279 patients with MVP. We found that T-wave inversion (OR 2.52; 95% CI: 1.90-3.33; p < 0.001), bileaflet involvement (OR 2.28; 95% CI: 1.69-3.09; p < 0.001), late gadolinium enhancement (OR 17.05; 95% CI: 3.41-85.22; p < 0.001), mitral annular disjunction (OR 3.71; 95% CI: 1.63-8.41; p < 0.002), and history of syncope (OR 6.96; 95% CI: 1.05-46.01; p = 0.044), but not female (OR 0.96; 95% CI: 0.46-2.01; p = 0.911), redundant leaflets (OR 4.30; 95% CI: 0.81-22.84; p = 0.087), or moderate-to-severe mitral regurgitation (OR 1.24; 95% CI: 0.65-2.37; p = 0.505), were associated with those events. CONCLUSION Bileaflet prolapse, T-wave inversion, mitral annular disjunction, late gadolinium enhancement, and history of syncope are high-risk phenotypes among population with MVP. Further research is needed to validate the risk stratification model and justify the role of primary prophylaxis against malignant arrhythmias.
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Affiliation(s)
- Juthipong Benjanuwattra
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Jakrin Kewcharoen
- Division of Cardiology, Loma Linda University Health, Loma Linda, CA, USA
| | - Phichayut Phinyo
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Thailand
| | | | - Mahmoud Abdelnabi
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Gaspar Del Rio-Pertuz
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Natnicha Leelaviwat
- Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Leenhapong Navaravong
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT, USA
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13
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Alqarawi W, Burwash IG, Krahn AD, Healey JS. Arrhythmic Mitral Valve Prolapse: Risk Assessment and Management. Can J Cardiol 2023; 39:1397-1409. [PMID: 37217162 DOI: 10.1016/j.cjca.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
Arrhythmic mitral valve prolapse (MVP) has gained great interest recently because of the increasing recognition of its potential role in unexplained cardiac arrest. Although evidence has accumulated to show the association of arrhythmic MVP (AMVP) with sudden cardiac death (SCD), risk stratification and management remain unclear. Physicians are faced with the challenges of screening for AMVP among MVP patients and the dilemma of when and how to intervene to prevent SCD in these patients. In addition, there is little guidance to help approach MVP patients who present with an otherwise unexplained cardiac arrest to know whether MVP was the primary cause of cardiac arrest or just an innocent bystander. Herein we review the epidemiology and definition of AMVP, the risk and mechanisms of SCD, and summarize the clinical evidence behind risk markers of SCD and therapeutic interventions that could potentially prevent it. We also propose an algorithm that provides guidance as to how to screen for AMVP and what therapeutic interventions to use. Last, we propose a diagnostic algorithm for approaching patients with otherwise unexplained cardiac arrest who are shown to have MVP.
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Affiliation(s)
- Wael Alqarawi
- Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia; Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Ian G Burwash
- Division of Cardiology, University of Ottawa Heart Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Andrew D Krahn
- Center for Cardiovascular Innovation, Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, and Hamilton Health Sciences, Hamilton, Ontario, Canada.
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14
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Timóteo AT. The dark side of mitral annular disjunction. Rev Port Cardiol 2023; 42:879-880. [PMID: 37156418 DOI: 10.1016/j.repc.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Affiliation(s)
- Ana Teresa Timóteo
- Cardiology Department, Santa Marta Hospital, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal; NOVA Medical School, Lisbon, Portugal.
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15
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Essayagh B, Sabbag A, El-Am E, Cavalcante JL, Michelena HI, Enriquez-Sarano M. Arrhythmic mitral valve prolapse and mitral annular disjunction: pathophysiology, risk stratification, and management. Eur Heart J 2023; 44:3121-3135. [PMID: 37561995 DOI: 10.1093/eurheartj/ehad491] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/11/2023] [Accepted: 07/19/2023] [Indexed: 08/12/2023] Open
Abstract
Mitral valve prolapse (MVP) is the most frequent valve condition but remains a conundrum in many aspects, particularly in regard to the existence and frequency of an arrhythmic form (AMVP) and its link to sudden cardiac death. Furthermore, the presence, frequency, and significance of the anatomic functional feature called mitral annular disjunction (MAD) have remained widely disputed. Recent case series and cohorts have shattered the concept that MVP is most generally benign and have emphasized the various phenotypes associated with clinically significant ventricular arrhythmias, including AMVP. The definition, evaluation, follow-up, and management of AMVP represent the focus of the present review, strengthened by recent coherent studies defining an arrhythmic MVP phenotypic that would affect a small subset of patients with MVP at concentrated high risk. The role of MAD in this context is of particular importance, and this review highlights the characteristics of AMVP phenotypes and MAD, their clinical, multimodality imaging, and rhythmic evaluation. These seminal facts lead to proposing a risk stratification clinical pathway with consideration of medical, rhythmologic, and surgical management and have been objects of recent expert consensus statements and of proposals for new research directions.
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Affiliation(s)
- Benjamin Essayagh
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
- Department of Echocardiography, Cardio X Clinic, Cannes, France
| | - Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer and the Sackler School of Medicine, Tel Aviv University, Ramat-Gan, Israel
| | - Edward El-Am
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - João L Cavalcante
- Department of Cardiovascular Medicine, Allina Health Minneapolis Heart Institute - Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
| | - Hector I Michelena
- From the Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street S.W., Rochester, MN 55905, USA
| | - Maurice Enriquez-Sarano
- Department of Cardiovascular Medicine, Allina Health Minneapolis Heart Institute - Abbott Northwestern Hospital, 800 E 28th St, Minneapolis, MN 55407, USA
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16
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Tfelt-Hansen J, Garcia R, Albert C, Merino J, Krahn A, Marijon E, Basso C, Wilde AAM, Haugaa KH. Risk stratification of sudden cardiac death: a review. Europace 2023; 25:euad203. [PMID: 37622576 PMCID: PMC10450787 DOI: 10.1093/europace/euad203] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/03/2023] [Indexed: 08/26/2023] Open
Abstract
Sudden cardiac death (SCD) is responsible for several millions of deaths every year and remains a major health problem. To reduce this burden, diagnosing and identification of high-risk individuals and disease-specific risk stratification are essential. Treatment strategies include treatment of the underlying disease with lifestyle advice and drugs and decisions to implant a primary prevention implantable cardioverter-defibrillator (ICD) and perform ablation of the ventricles and novel treatment modalities such as left cardiac sympathetic denervation in rare specific primary electric diseases such as long QT syndrome and catecholaminergic polymorphic ventricular tachycardia. This review summarizes the current knowledge on SCD risk according to underlying heart disease and discusses the future of SCD prevention.
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Affiliation(s)
- Jacob Tfelt-Hansen
- Cardiology Department, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, Copenhagen 2100, Denmark
- Section of Forensic Genetics, Department of Forensic Medicine, Copenhagen University, Frederik V’s Vej 11, Copenhagen 2100, Denmark
| | - Rodrigue Garcia
- Cardiology Department, University Hospital of Poitiers, 2 rue de la Milétrie, Poitiers 86000, France
- Centre d'Investigation Clinique 1402, University Hospital of Poitiers, 2 rue de la Milétrie, Poitiers 86000, France
| | - Christine Albert
- Cardiology Department, Smidt Heart Institute, Cedars-Sinai Hospital, Los Angeles, CA, USA
| | - Jose Merino
- Department of Cardiology, La Paz University Hospital, IdiPaz, P. Castellana, 261, Madrid 28046, Spain
- Department of Cardiology, Viamed Santa Elena University Hospital, C/La Granja, 8, Madrid 28003, Spain
| | - Andrew Krahn
- Centre for Cardiovascular Innovation, Division of Cardiology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eloi Marijon
- Cardiology Department, European Georges Pompidou Hospital, Paris, France
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani 2, Padova 35121, Italy
| | - Arthur A M Wilde
- Department of Cardiology, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
- Department of Cardiology, Heart Failure and Arrhythmias, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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