Mitral valve prolapse morphofunctional features by cardiovascular magnetic resonance: more than just a valvular disease

Abstract

Introduction Mitral valve (MV) prolapse (MVP) is a primary valvular abnormality. We hypothesized that additionally there are concomitant abnormalities of the left ventricle (LV) and MV apparatus in this entity even in the absence of significant mitral regurgitation (MR). Objective To characterize MV and LV anatomic and functional features in MVP with preserved LV ejection fraction, with and without significant MR, using cardiovascular magnetic resonance (CMR). Methods Consecutive MVP patients (n = 80, mean 52 years, 37% males) with preserved LV ejection fraction, and 44 controls (46 years, 52% males) by CMR were included, as well as 13 additional patients with “borderline” MVP. From cine images we quantified LV volumes, MV and LV anatomic measurements (including angle between diastolic and systolic annular planes, annular displacement, and basal inferolateral hypertrophy) and, using feature tracking, longitudinal and circumferential peak systolic strains. Results Significant MR was found in 46 (56%) MVP patients. Compared with controls, MVP patients had LV enlargement, basal inferolateral hypertrophy, higher posterior annular excursion, and reduced shortening of the papillary muscles. LV basal strains were significantly increased, particularly in several basal segments. These differences remained significant in patients without significant MR, and many persisted in “borderline” MVP. Conclusions In patients with MVP and preserved LV ejection fraction there is LV dilatation, basal inferolateral hypertrophy, exaggerated posterior annular displacement and increased basal deformation, even in the absence of significant MR or overt MVP. These findings suggest that MVP is a disease not only of the MV but also of the adjacent myocardium.

Mitral Valve Prolapse and Mitral Annular Disjunction Arrhythmic Syndromes: Diagnosis, Risk Stratification and Management

“…The flattening of the mitral annulus increases mechanical stretch on the mitral leaflets [37] and PM causing PM elongation and resulting in leaflet degeneration, regional hypertrophy and subsequent fibrosis [4,38]. This hypothesis is further supported by CMR findings where LGE enhancement is confirmed in the areas prone to mechanical stretch [3,15] (Fig. 2).…”

Diagnosis of Mitral Valve Prolapse: Much More than Simple Prolapse. Multimodality Approach to Risk Stratification and Therapeutic Management

“…However, no correlation between these findings and VA was reported [29]. Finally, in another study evaluating MVP patients using CMR, Daza et al [42] found that, compared to controls, MVP patients had LV enlargement, basal inferolateral hypertrophy, increased basal longitudinal strain, particularly in the anterior, anterolateral, and inferolateral segments, and more frequently MAD, regardless of the presence of significant MR and also in the presence of borderline MVP, concluding that MVP is a complex disease that involves not only the valve, but also the LV and should be seen as a "ventriculo-mitral unit". CMR can help in stratifying MVP patients at risk for malignant arrhythmias as it allows the detection of either focal or diffuse fibrosis that may be responsible for reentry circuits, providing also evidence of early structural and functional remodeling that may evolve to fibrosis, although these findings need wider clinical investigation.…”

“…CMR is the gold standard for LV and right ventricular volumetric assessment. CMR can also provide additional and more precise information on mitral valve characteristics, is more sensitive in MAD and curling identification [31], localized hypertrophy [14,42], and LV myocardial strain [42], although it has a poorer performance than TTE. Tissue characterization is another piece of the MVP puzzle that CMR adds.…”

Highlights of the Virtual Society for Cardiovascular Magnetic Resonance 2022 Scientific Conference: CMR: improving cardiovascular care around the world

“…The Gerald M. Prohost award for the best scientific manuscript for 2021 went to Dr. Theo Pezel and colleagues for their study on the prognostic value of vasodilator stress perfusion CMRafter inconclusive stress testing [ 32 ]. Dr Angelica Romero Daza and colleagues were the Pohost runner’s up for their article on assessment of morpho-functional features of mitral valve prolapse on CMR [ 33 ]. The Dudley Pennell award for the manuscript contributing the most to the June 2021 JCMR impact factor (currently 5.364) was presented to Dr Wnjia Bai and colleagues for their article on automated CMR image analysis by fully convolutional neural networks [ 34 ].…”