Prevalence of Diastolic and Systolic Mitral Annular Disjunction in Patients With Mitral Valve Prolapse - 02/01/25
Abstract |
Backgrounds |
Mitral annular disjunction (MAD) is commonly evaluated at end systole. However, a systolic-only disjunction is merely apparent, and 2 distinct phenotypes have been identified: True-MAD (atrial displacement of the posterior leaflet in diastole and systole) and Pseudo-MAD (apparent displacement in systole only). The prevalence of True-MAD and Pseudo-MAD in mitral valve prolapse (MVP) is not known. The aim of this study was to assess the prevalence of True-MAD and Pseudo-MAD in myxomatous MVP patients by transthoracic echocardiography (TTE) and to validate TTE compared to cardiac magnetic resonance (CMR; reference standards).
Methods |
Consecutive patients who underwent TTE for MVP were included. Mitral annular phenotype was evaluated in the TTE parasternal long-axis view. Accuracy (against CMR) and intra-/interrater reliability of TTE were also assessed.
Results |
Six hundred three consecutive patients were included. The prevalence of True-MAD and Pseudo-MAD was 7% (42) and 37% (221) (P < .05), respectively. Accordingly, 221 of 263 (84%) patients classically classified as “MAD” would have been reclassified as Pseudo-MAD. Pseudo-MAD prevalence and systolic length increased with higher mitral regurgitation (MR) severity (23% for mild MR, 36% for moderate MR, 44% for severe MR [P < .05]; 6 ± 2 mm for mild MR; 8 ± 2 mm for moderate MR; 10 ± 2 mm for severe MR [P < .05]), while True-MAD prevalence was consistent across MR grades. Pseudo-MAD was linked to systolic curling and Pickelhaube. Transthoracic echocardiography showed an overall accuracy of 0.89 (Cohen k 0.80), a substantial interrater agreement of 0.87 (k = 0.76), and an almost perfect intrarater agreement of 0.93 (k = 0.85).
Conclusions |
True-MAD, unlike Pseudo-MAD, is rare in patients with MVP. Pseudo-MAD is associated with the grade of MR and other echocardiographic features of advanced myxomatous degeneration. Transthoracic echocardiography is an accurate and reliable first-line method to assess mitral annulus morphology in MVP.
Le texte complet de cet article est disponible en PDF.Central Illustration |
Patients with MVP were subclassified by TTE based on the mitral annulus phenotype in systole and diastole. True-MAD was defined as a clear separation between the central part of the posterior leaflet (P2) and the ventricular myocardium in both diastole and systole. Pseudo-MAD was defined as the presence of only systolic apparent disjunction. Finally, No-MAD was defined as normal leaflet insertion through the entire cardiac cycle. Transthoracic echocardiography was validated against the reference standard CMR. Pseudo-MAD, unlike True-MAD, was highly prevalent in the overall cohort of patients (37%), and its prevalence increased with higher degrees of MR severity (P < .05), while True-MAD prevalence remained almost the same in all MR severity grades. Values are expressed as percentages. ∗P < .05 mild MR vs moderate MR. †P < .05 mild MR vs severe MR. ‡P < .05 moderate MR vs severe MR.
Patients with MVP were subclassified by TTE based on the mitral annulus phenotype in systole and diastole. True-MAD was defined as a clear separation between the central part of the posterior leaflet (P2) and the ventricular myocardium in both diastole and systole. Pseudo-MAD was defined as the presence of only systolic apparent disjunction. Finally, No-MAD was defined as normal leaflet insertion through the entire cardiac cycle. Transthoracic echocardiography was validated against the reference standard CMR. Pseudo-MAD, unlike True-MAD, was highly prevalent in the overall cohort of patients (37%), and its prevalence increased with higher degrees of MR severity (P < .05), while True-MAD prevalence remained almost the same in all MR severity grades. Values are expressed as percentages. ∗P < .05 mild MR vs moderate MR. †P < .05 mild MR vs severe MR. ‡P < .05 moderate MR vs severe MR.
Central IllustrationPatients with MVP were subclassified by TTE based on the mitral annulus phenotype in systole and diastole. True-MAD was defined as a clear separation between the central part of the posterior leaflet (P2) and the ventricular myocardium in both diastole and systole. Pseudo-MAD was defined as the presence of only systolic apparent disjunction. Finally, No-MAD was defined as normal leaflet insertion through the entire cardiac cycle. Transthoracic echocardiography was validated against the reference standard CMR. Pseudo-MAD, unlike True-MAD, was highly prevalent in the overall cohort of patients (37%), and its prevalence increased with higher degrees of MR severity (P < .05), while True-MAD prevalence remained almost the same in all MR severity grades. Values are expressed as percentages. ∗P < .05 mild MR vs moderate MR. †P < .05 mild MR vs severe MR. ‡P < .05 moderate MR vs severe MR.Le texte complet de cet article est disponible en PDF.
Highlights |
• | Anatomical substrate of MAD implies its presence through the entire cardiac cycle. |
• | Pseudo-MAD is the apparent systolic-only disjunction of the PML. |
• | True-MAD is a real PML insertion on the atrial wall in both diastole and systole. |
• | Pseudo-MAD is more common than True-MAD. |
• | Pseudo-MAD is associated to MR grade and features of the arrhythmic MVP complex. |
Keywords : Pseudo-MAD, MAD, Ventricular arrhythmias, Mitral annulus, Arrhythmic mitral valve prolapse, Mitral regurgitation
Abbreviations : 3D, ANOVA, CCT, CMR, LGE, LV, MAD, MVP, MR, OR, PLAX, PML, SCD, TEE, TTE
Plan
Vol 38 - N° 1
P. 1-11 - janvier 2025 Retour au numéro
Article précédent
- Guide for Authors
- Mitral Annular Disjunction: An Approximation to the Truth
- Hector I. Michelena, Joseph J. Maleszewski, Jeremy D. Collins
Bienvenue sur EM-consulte, la référence des professionnels de santé.
L’accès au texte intégral de cet article nécessite un abonnement.
Déjà abonné à cette revue ?