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Association Between Malignant Mitral Valve Prolapse and Sudden Cardiac DeathA Review

Educational Objective
To review the pathogenesis of ventricular arrhythmias and sudden cardiac death (SCD) in the setting of mitral valve prolapse (MVP).
1 Credit CME

Importance  Malignant arrhythmic mitral valve prolapse (MVP) phenotype poses a substantial risk of sudden cardiac death (SCD), and an estimated 26 000 individuals in the United States are at risk of SCD per year. Thus, identifying risk-stratification strategies for SCD is imperative.

Observations  Patients with MVP have a heterogenous clinical spectrum, ranging from a benign course to a devastating complication such as SCD. Some of the high-risk markers of MVP, which are identified electrocardiographically, include inverted or biphasic T waves, QT dispersion, QT prolongation, and premature ventricular contractions originating from the left ventricular outflow tract and papillary muscles. Morphofunctional characteristics of SCD are leaflet thickness of 5 mm or greater, mitral annulus disjunction, paradoxical systolic increase of the mitral annulus diameter, increased tissue Doppler velocity of the mitral annulus, and higher mechanical dispersion on echocardiography and fibrosis identified by late gadolinium enhancement on cardiac magnetic resonance imaging.

Conclusions and Relevance  Findings from this review suggest that SCD can occur earlier in the course of MVP from complex arrhythmias that are triggered by the repeated tugging and traction of the chordopapillary muscle unit and basal mid-myocardium, even before macrofibrosis can be identified in these regions by late gadolinium enhancement on cardiac magnetic resonance imaging. Some of the newer markers identified by speckle-tracking Doppler, such as mechanical dispersion, myocardial work index, and postsystolic shortening, need further validation in a larger population.

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Article Information

Accepted for Publication: February 7, 2020.

Corresponding Author: A. Jamil Tajik, MD, Aurora Cardiovascular and Thoracic Services, Aurora St Luke’s Medical Center, 2801 W Kinnickinnic River Pkwy, Ste 880, Milwaukee, WI 53215 (

Published Online: May 27, 2020. doi:10.1001/jamacardio.2020.1412

Author Contributions: Drs Muthukumar and Tajik had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Muthukumar, Jahangir, Khandheria, Tajik.

Acquisition, analysis, or interpretation of data: Muthukumar, Jan, Perez Moreno, Tajik.

Drafting of the manuscript: Muthukumar, Jan, Perez Moreno.

Critical revision of the manuscript for important intellectual content: Jahangir, Jan, Perez Moreno, Khandheria, Tajik.

Statistical analysis: Perez Moreno.

Supervision: Jahangir, Perez Moreno, Khandheria, Tajik.

Conflict of Interest Disclosures: None reported.

Additional Contributions: Jennifer Pfaff, BA, and Susan Nord, MA, Aurora Cardiovascular and Thoracic Services, assisted with editorial preparation of the manuscript. Brian Schurrer, AA, and Brian Miller, AA, Advocate Aurora Research, assisted with the figures. These individuals received no additional compensation, outside of their usual salary, for their contributions.

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