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Markman TM, Marchlinski FE, Callans DJ, Frankel DS. Programmed Ventricular Stimulation: Risk Stratification and Guiding Antiarrhythmic Therapies. JACC Clin Electrophysiol 2024; 10:1489-1507. [PMID: 38661601 DOI: 10.1016/j.jacep.2024.02.034] [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: 01/16/2024] [Accepted: 02/13/2024] [Indexed: 04/26/2024]
Abstract
Electrophysiologic testing with programmed ventricular stimulation (PVS) has been utilized to induce ventricular tachycardia (VT), thereby improving risk stratification for patients with ischemic and nonischemic cardiomyopathies and determining the effectiveness of antiarrhythmic therapies, especially catheter ablation. A variety of procedural aspects can be modified during PVS in order to alter the sensitivity and specificity of the test including the addition of multiple baseline pacing cycle lengths, extrastimuli, and pacing locations. The definition of a positive result is also critically important, which has varied from exclusively sustained monomorphic VT (>30 seconds) to any ventricular arrhythmia regardless of morphology. In this review, we discuss the history of PVS and evaluate its role in sudden cardiac death risk stratification in a variety of patient populations. We propose an approach to future investigations that will capitalize on the unique ability to vary the sensitivity and specificity of this test. We then discuss the application of PVS during and following catheter ablation. The strategies that have been utilized to improve the efficacy of intraprocedural PVS are highlighted during a discussion of the limitations of this probabilistic strategy. The role of noninvasive programmed stimulation is also reviewed in predicting recurrent VT and informing management decisions including repeat ablations, modifications in antiarrhythmic drugs, and implantable cardioverter-defibrillator programming. Based on the available evidence and guidelines, we propose an approach to future investigations that will allow clinicians to optimize the use of PVS for risk stratification and assessment of therapeutic efficacy.
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Affiliation(s)
- Timothy M Markman
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Francis E Marchlinski
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David J Callans
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David S Frankel
- Cardiovascular Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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2
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Özyıldırım S, Guven B, Yumuk MT, Barman HA, Dogan O, Topel C, Atici A, Donmez A, Kucukoglu MS, Dogan SM. Evaluation of left ventricular function in patients with mitral annular disjunction using speckle tracking echocardiography. Echocardiography 2024; 41:e15813. [PMID: 38628060 DOI: 10.1111/echo.15813] [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: 06/10/2023] [Revised: 03/22/2024] [Accepted: 03/26/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Mitral annular disjunction (MAD) is a structural abnormality characterized by the systolic detachment of the posterior mitral annulus and the ventricular myocardium. It is usually observed coexistent with mitral valve prolapse (MVP) and associated with a mechanical dysfunction despite preserved electrical isolation function of the mitral annulus. This study aimed to evaluate left ventricular (LV) function using speckle tracking echocardiography in MVP patients with MAD. METHODS This study was designed as a prospective, single-center study including 103 patients with MVP and 40 age- and sex-matched control subjects. Transthoracic echocardiography and cardiac magnetic resonance imaging were performed to assess LV function and MAD presence. RESULTS MAD (+) MVP (n = 34), MAD (-) MVP (n = 69), and control (n = 40) groups were enrolled in the study. Among the MVP patients, 34 (33%) had MAD. T-negativity in the inferior leads on electrocardiography was more frequent in the MAD (+) group than in the MAD (-) patients (4.3% vs. 20.6%, p = .014). Mitral regurgitation degree, Pickelhaube sign (17.6% vs. 1.4%, p = .005), and late gadolinium enhancement frequency (35.3% vs. 10.6%, p = .002) were significantly higher in MAD (+) patients. MAD (+) patients had significantly impaired global longitudinal strain (-23.1 ± 2.1 vs. -23.5 ± 2.3, p < .001), basal longitudinal strain (BLS) (-19.6 ± 1.5 vs. -20.5 ± 1.9, p < .001), Mid-Ventricular Longitudinal Strain (-22.2 ± 1.7 vs. -23.2 ± 2.2, p < .001) and LA strain (-24.5 ± 3.9 vs. -27.2 ± 3.6, p < .001) when compared to MAD (-) MVP patients, despite similar LV ejection fraction. All these values of MVP patients were also significantly lower than the control group. The mean MAD distance was 7.8 ± 3.2 mm in MAD (+) patients. Patients with two or more symptoms were higher in the MAD (+) group than in the MAD (-) group (4.3% vs. 44.1%, p < .001). CONCLUSION This study demonstrated a significant decrease in longitudinal strain in MVP patients with MAD, indicating myocardial dysfunction. These findings suggest that MAD may contribute to LV dysfunction and highlight the importance of early detection in younger patients. Further research is needed to explore the functional implications and long-term outcomes of MAD.
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Affiliation(s)
- Serhan Özyıldırım
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Baris Guven
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mehmet Tugay Yumuk
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Hasan Ali Barman
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Omer Dogan
- Department of Cardiology, Ministry of Health, Istinye State Hospital, Istanbul, Turkey
| | - Cagdas Topel
- Department of Radiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Adem Atici
- Department of Cardiology, Faculty of Medicine, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ayça Donmez
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Mehmet Serdar Kucukoglu
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Sait Mesut Dogan
- Institute of Cardiology, Department of Cardiology, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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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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Berruezo A, Penela D, Jáuregui B, de Asmundis C, Peretto G, Marrouche N, Trayanova N, de Chillou C. Twenty-five years of research in cardiac imaging in electrophysiology procedures for atrial and ventricular arrhythmias. Europace 2023; 25:euad183. [PMID: 37622578 PMCID: PMC10450789 DOI: 10.1093/europace/euad183] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 06/14/2023] [Indexed: 08/26/2023] Open
Abstract
Catheter ablation is nowadays considered the treatment of choice for numerous cardiac arrhythmias in different clinical scenarios. Fluoroscopy has traditionally been the primary imaging modality for catheter ablation, providing real-time visualization of catheter navigation. However, its limitations, such as inadequate soft tissue visualization and exposure to ionizing radiation, have prompted the integration of alternative imaging modalities. Over the years, advancements in imaging techniques have played a pivotal role in enhancing the safety, efficacy, and efficiency of catheter ablation procedures. This manuscript aims to explore the utility of imaging, including electroanatomical mapping, cardiac computed tomography, echocardiography, cardiac magnetic resonance, and nuclear cardiology exams, in helping electrophysiology procedures. These techniques enable accurate anatomical guidance, identification of critical structures and substrates, and real-time monitoring of complications, ultimately enhancing procedural safety and success rates. Incorporating advanced imaging technologies into routine clinical practice has the potential to further improve clinical outcomes of catheter ablation procedures and pave the way for more personalized and precise ablation therapies in the future.
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Affiliation(s)
- Antonio Berruezo
- Arrhythmia Unit, Teknon Medical Centre, Carrer de Vilana, 12, 08022 Barcelona, Spain
| | - Diego Penela
- Arrhythmia Unit, Humanitas Research Hospital, Via Alessandro Manzoni, 56, 20089 Rozzano Milan, Italy
| | - Beatriz Jáuregui
- Arrhythmia Unit - Miguel Servet University Hospital, P.º de Isabel la Católica, 1-3, 50009 Zaragoza, Spain
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Universitair Ziekenhuis Brussel-Vrije Universiteit Brussel, Blvd Géneral Jacques 137, 1050 Ixelles, Brussels, Belgium
| | - Giovanni Peretto
- Arrhythmia Unit, Ospedale San Raffaele Hospital, Via Olgettina, 60, 20132 Milan, Italy
| | - Nassir Marrouche
- Department of Cardiology, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112, USA
| | - Natalia Trayanova
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
- Department of Applied Math and Statistics, Johns Hopkins University, Baltimore, MD 21218, USA
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Christian de Chillou
- INSERM IADI U1254, University Hospital Nancy, University of Lorraine, 29 Av. du Maréchal de Lattre de Tassigny, 54000 Nancy, France
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Chakrabarti AK, Deshmukh A, Liang JJ, Madamanchi C, Ghannam M, Morady F, Bogun F. Mitral Annular Substrate and Ventricular Arrhythmias in Arrhythmogenic Mitral Valve Prolapse With Mitral Annular Disjunction. JACC Clin Electrophysiol 2023; 9:1265-1275. [PMID: 37086231 DOI: 10.1016/j.jacep.2023.02.010] [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: 10/06/2022] [Revised: 01/18/2023] [Accepted: 02/08/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND In patients with bileaflet mitral valve prolapse (MVP), mitral annular disjunction (MAD) is associated with increased risk of sudden cardiac death via incompletely understood mechanisms. OBJECTIVES This study assessed the substrate for ventricular arrhythmias in patients with bileaflet MVP and MAD as well as outcomes of catheter ablation with an emphasis on sustained, monomorphic ventricular tachycardia (VT). METHODS A total of 18 consecutive patients (11 women, mean age 54 ± 15 years) with bileaflet MVP and MAD underwent catheter ablation for VT, and/or premature ventricular complexes (PVCs). Eight patients had a prior cardiac arrest. RESULTS PVCs were targeted for ablation in all 18 patients (symptomatic PVCs n = 15, PVC-induced ventricular fibrillation n = 3). Sustained monomorphic VT was targeted in 7 of 18 patients. Electroanatomic mapping showed low voltage in the area of the mitral annulus corresponding to VT target sites in 6 of 7 patients with sustained VT. Four of 7 patients had low voltage in the areas of MAD. Six of 7 patients with VT were rendered noninducible post-ablation. The PVC burden was reduced from 11.0% ± 10.4% to 4.0% ± 5.5% (P = 0.004). Over a mean follow-up of 33.9 ± 43.4 months, no VTs recurred. There were no major complications. No repeat ablations for VT occurred. Five of 18 patients required repeat ablation for PVCs. CONCLUSIONS In patients with bileaflet MVP and MAD undergoing catheter ablation, the mitral valve annulus often contains low-voltage areas harboring the substrate for monomorphic VT and PVCs. Ablation in these patients was safe and improved arrhythmia control.
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Affiliation(s)
- Apurba K Chakrabarti
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amrish Deshmukh
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Jackson J Liang
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Chaitanya Madamanchi
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael Ghannam
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Fred Morady
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Frank Bogun
- Section of Electrophysiology, Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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Sabbag A, Essayagh B, Barrera JDR, Basso C, Berni A, Cosyns B, Deharo JC, Deneke T, Di Biase L, Enriquez-Sarano M, Donal E, Imai K, Lim HS, Marsan NA, Turagam MK, Peichl P, Po SS, Haugaa KH, Shah D, de Riva Silva M, Bertrand P, Saba M, Dweck M, Townsend SN, Ngarmukos T, Fenelon G, Santangeli P, Sade LE, Corrado D, Lambiase P, Sanders P, Delacrétaz E, Jahangir A, Kaufman ES, Saggu DK, Pierard L, Delgado V, Lancellotti P. EHRA expert consensus statement on arrhythmic mitral valve prolapse and mitral annular disjunction complex in collaboration with the ESC Council on valvular heart disease and the European Association of Cardiovascular Imaging endorsed cby the Heart Rhythm Society, by the Asia Pacific Heart Rhythm Society, and by the Latin American Heart Rhythm Society. Europace 2022; 24:1981-2003. [PMID: 35951656 DOI: 10.1093/europace/euac125] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 07/04/2022] [Indexed: 12/14/2022] Open
Affiliation(s)
- Avi Sabbag
- The Davidai Center for Rhythm Disturbances and Pacing, Chaim Sheba Medical Center, Tel Hashomer 52621, Israel
| | - Benjamin Essayagh
- Department of Cardiovascular Medicine, Simone Veil Hospital, Cannes 06400, France.,Department of Cardiovascular Medicine, Mayo Clinic, Rochester 55905, Minnesota
| | | | - Cristina Basso
- Dipartimento di Scienze Cardio-Toraco-Vascolari e Sanità Pubblica, Università degli Studi di Padova, Padova 35128, Italy
| | - Ana Berni
- Cardiology and Cardiac Electrophysiology, EP Lab. Hospital Angeles Pedregal. Mexico City 10700, Board member, Mexican Society of Cardiology
| | - Bernard Cosyns
- Cardiology Department, Centrum voor hart en vaatziekten, Universitair Ziekenhuis Brussel, Free University of Brussels, Brussels 1090, Belgium
| | - Jean-Claude Deharo
- Department of Cardiology, L'hôpital de la Timone, Marseille, 13005, France
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, 97616, Germany
| | - Luigi Di Biase
- Albert Einstein College of Medicine at Montefiore Hospital, New York, NY 10467, USA
| | | | - Erwan Donal
- Service de Cardiologie, CCP-CHU Pontchaillou, Rennes 35033, France
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, National Hospital Organization Kure Medical Center and Chugoku Cancer Center, Hiroshima 737-0023, Japan
| | - Han S Lim
- Department of Cardiology, Austin and Northern Health, University of Melbourne, Melbourne 3010, Australia
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Petr Peichl
- Department of Cardiology, Institute for Clinical and Experimental Medicine (IKEM), Prague 73117, Czech Republic
| | - Sunny S Po
- Heart Rhythm Institute and Section of Cardiovascular Diseases, University of Oklahoma Health Sciences Center, Oklahoma City, OK 0372, USA
| | - Kristina Hermann Haugaa
- ProCardio Center for Innovation, Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Dipen Shah
- Cantonal Hospital, Cardiology Department, CH-1211 Geneva, Switzerland
| | - Marta de Riva Silva
- Department of Cardiology, Leiden University Medical Center, Leiden 2333, The Netherlands
| | - Philippe Bertrand
- Ziekenhuis Oost-Limburg, Hasselt University, Genk, Hasselt 3600, Belgium
| | - Magdi Saba
- Consultant and Reader in Cardiac Electrophysiology, Director, Advanced Ventricular Arrhythmia Training and Research Program, St. George's Hospital NHS Foundation Trust, St. George's, University of London, SW17 0QT, UK
| | - Marc Dweck
- Centre for cardiovascular science, University of Edinburgh, EH16 4TJ, UK
| | - Santiago Nava Townsend
- Instituto Nacional De Cardiologia Ich, Electrophysiology Department, Mexico Df 14080, Mexico
| | - Tachapong Ngarmukos
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok 73170, Thailand
| | - Guilherme Fenelon
- Coordenador - Centro de Arritmia, Hospital Israelita Albert Einstein, São Paulo - SP, 05652-900, Brazil
| | | | - Leyla Elif Sade
- University of Pittsburgh, UPMC, Heart and Vascular Institute, ittsburgh, PA 15219, USA.,C.H.U. du Sart-Tilman, Universite de Liege, Liege 4000, Belgium
| | - Domenico Corrado
- Full Professor of Cardiovascular Medicine, Director, Inherited Arrhythmogenic Cardiomyopathies and Sports Cardiology Unit, Dept. of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padova 35122, Italy
| | - Pier Lambiase
- UCL & Barts Heart Centre, Co-Director of Cardiovascular Research Barts NHS Trust, Inherited Arrhythmia Clinical Lead, UCL MRC DTP Theme Lead, BHRS Committee Research Lead, Institute of Cardiovascular Science, UCL, Department of Cardiology, Barts Heart Centre E1 1BB, UK
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, University of Adelaide, South Australia 5000, Australia
| | - Etienne Delacrétaz
- Clinique Cecil Hirslanden Lausanne & University Hospital Fribourg, Cardiology 1003, Switzerland
| | - Arshad Jahangir
- University of Wisconsin School of Medicine and Public Health, Milwaukee, MI 53705, USA
| | - Elizabeth S Kaufman
- Clinical Electrophysiologist, MetroHealth Medical Center, Professor, Case Western Reserve University 44106, USA
| | - Daljeet Kaur Saggu
- Consultant Cardiologist and Electrophysiologist, AIG HOSPITAL, Hyderabad 500032, India
| | - Luc Pierard
- C.H.U. du Sart-Tilman, Universite de Liege, Liege 4000, Belgium
| | - Victoria Delgado
- Heart Institute, Hospital University Germans Trias i Pujol, Badalona 08916, Spain
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Mitral Annular Disjunction: Associated Pathologies and Clinical Consequences. Curr Cardiol Rep 2022; 24:1933-1944. [PMID: 36331783 DOI: 10.1007/s11886-022-01806-1] [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] [Accepted: 10/10/2022] [Indexed: 11/06/2022]
Abstract
PURPOSE OF REVIEW To provide an overview of mitral annular disjunction (MAD) and to discuss important challenges in diagnosis and management of MAD. RECENT FINDINGS MAD has regained interest in the context of sudden cardiac death (SCD) in patients with mitral valve prolapse (MVP), coined as the "arrhythmic" MVP syndrome. In addition, MAD in isolation was recently suggested to be associated with severe arrhythmia and SCD. There is a lack of consensus on the definition of MAD and the imaging modality to be used for diagnosing MAD, and the therapeutic implications of MAD remain uncertain. Furthermore, the exact mechanism underlying the association of MAD with SCD remains largely unexplored.
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8
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Kelley BP, Chaudry AM, Syed FF. Developing a Mechanistic Approach to Sudden Death Prevention in Mitral Valve Prolapse. J Clin Med 2022; 11:jcm11051285. [PMID: 35268384 PMCID: PMC8910972 DOI: 10.3390/jcm11051285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 11/30/2022] Open
Abstract
Sudden cardiac death (SCD) from ventricular fibrillation (VF) can occur in mitral valve prolapse (MVP) in the absence of other comorbidities including mitral regurgitation, heart failure or coronary disease. Although only a small proportion with MVP are at risk, it can affect young, otherwise healthy adults, most commonly premenopausal women, often as the first presentation of MVP. In this review, we discuss arrhythmic mechanisms in MVP and mechanistic approaches for sudden death risk assessment and prevention. We define arrhythmogenic or arrhythmic MVP (AMVP) as MVP associated with complex and frequent ventricular ectopy, and malignant MVP (MMVP) as MVP with high risk of SCD. Factors predisposing to AMVP are myxomatous, bileaflet MVP and mitral annular disjunction (MAD). Data from autopsy, cardiac imaging and electrophysiological studies suggest that ectopy in AMVP is due to inflammation, fibrosis and scarring within the left ventricular (LV) base, LV papillary muscles and Purkinje tissue. Postulated mechanisms include repetitive injury to these regions from systolic papillary muscle stretch and abrupt mitral annular dysmotility (excursion and curling) and diastolic endocardial interaction of redundant mitral leaflets and chordae. Whereas AMVP is seen relatively commonly (up to 30%) in those with MVP, MVP-related SCD is rare (2–4%). However, the proportion at risk (i.e., with MMVP) is unknown. The clustering of cardiac morphological and electrophysiological characteristics similar to AMVP in otherwise idiopathic SCD suggests that MMVP arises when specific arrhythmia modulators allow for VF initiation and perpetuation through action potential prolongation, repolarization heterogeneity and Purkinje triggering. Adequately powered prospective studies are needed to assess strategies for identifying MMVP and the primary prevention of SCD, including ICD implantation, sympathetic modulation and early surgical mitral valve repair. Given the low event rate, a collaborative multicenter approach is essential.
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Affiliation(s)
- Brian P. Kelley
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA;
| | | | - Faisal F. Syed
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599, USA;
- Correspondence:
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