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Original research
Multimodality imaging assessment of mitral annular disjunction in mitral valve prolapse
  1. Valentina Mantegazza,
  2. Valentina Volpato,
  3. Paola Gripari,
  4. Sarah Ghulam Ali,
  5. Laura Fusini,
  6. Gianpiero Italiano,
  7. Manuela Muratori,
  8. Gianluca Pontone,
  9. Gloria Tamborini,
  10. Mauro Pepi
  1. Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
  1. Correspondence to Dr Valentina Mantegazza, Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milano 20138, Italy; valentina.mantegazza{at}


Objective Mitral annular disjunction (MAD) is an abnormality linked to mitral valve prolapse (MVP), possibly associated with malignant ventricular arrhythmias. We assessed the agreement among different imaging techniques for MAD identification and measurement.

Methods 131 patients with MVP and significant mitral regurgitation undergoing transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were retrospectively enrolled. Transoesophageal echocardiography (TOE) was available in 106 patients. MAD was evaluated in standard long-axis views (four-chamber, two-chamber, three-chamber) by each technique.

Results Considering any-length MAD, MAD prevalence was 17.3%, 25.5%, 42.0% by TTE, TOE and CMR, respectively (p<0.05). The agreement on MAD identification was moderate between TTE and CMR (κ=0.54, 95% CI 0.49 to 0.59) and good between TOE and CMR (κ=0.79, 95% CI 0.74 to 0.84). Assuming CMR as reference and according to different cut-off values for MAD (≥2 mm, ≥4 mm, ≥6 mm), specificity (95% CI) of TTE and TOE was 99.6 (99.0 to 100.0)% and 98.7 (97.4 to 100.0)%; 99.3 (98.4 to 100.0)% and 97.6 (95.8 to 99.4)%; 97.8 (96.2 to 99.3)% and 93.2 (90.3 to 96.1)%, respectively; sensitivity (95% CI) was 43.1 (37.8 to 48.4)% and 74.5 (69.4 to 79.5)%; 54.0 (48.7 to 59.3)% and 88.9 (85.2 to 92.5)%; 88.0 (84.5 to 91.5)% and 100.0 (100.0 to 100.0)%, respectively. MAD length was 8.0 (7.0-10.0), 7.0 (5.0-8.0], 5.0 (4.0-7.0) mm, respectively by TTE, TOE and CMR. Agreement on MAD measurement was moderate between TTE and CMR (ρ=0.73) and strong between TOE and CMR (ρ=0.86).

Conclusions An integrated imaging approach could be necessary for a comprehensive assessment of patients with MVP and symptoms suggestive for arrhythmias. If echocardiography is fundamental for the anatomic and haemodynamic characterisation of the MV disease, CMR may better identify small length MAD as well as myocardial fibrosis.

  • cardiac magnetic resonance (CMR) imaging
  • echocardiography
  • mitral regurgitation

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  • Contributors VM and MP contributed to the conception and design of the study. VV, PG, SGA, LF, GI, MM and GT contributed to data collection, analysis and interpretation. VM, GP and MP drafted and revised the manuscript. All authors read and approved the manuscript before its submission.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests GP reports research grants and/or honorarium as speaker from GE Healthcare, Bracco, Bayer, Medtronic and Heartflow.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Ethics Committee (R1168/20-CCM 1230). Informed consent was obtained from all subjects.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.

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