Mitral Annular Disjunction: A Roadmap for the Surgeon
European Journal of Cardio-Thoracic Surgery, vol. 68
Abstract
OBJECTIVES: Mitral annular disjunction (MAD) is a structural abnormality of the mitral annulus fibrosus, associated with myxomatous leaflet degeneration, mitral valve prolapse (MVP), and ventricular arrhythmias. The combination of annular dilatation and abnormal annular motion increases mechanical stress on the mitral leaflets, triggering the degenerative process. METHODS: This review summarizes the major pathophysiologic, diagnostic and therapeutic measures for the treatment of patients with MAD and an indication for mitral surgery. RESULTS: The diagnosis is primarily based on non-invasive imaging techniques. Echocardiography is the first choice due to its ability to assess real-time mitral valve function. Cardiac computed tomography and magnetic resonance imaging provide more detailed information on the extent of MAD and the presence of calcifications. Indications for surgical mitral valve treatment are based on current recommendations. In cases with MAD and moderate mitral regurgitation, early intervention may be advocated in the presence of arrhythmogenic MVP. Long-term outcomes after treatment are assessed through multimodal imaging and electrocardiogram monitoring. A ring annuloplasty is an important cornerstone of treatment. Stabilization of the mitral annulus abolishes functional prolapse and increases the antiarrhythmic effect of mitral surgery. However, postoperative arrhythmic burden may persist in some cases, requiring continuous monitoring and sometimes an additional device therapy. CONCLUSIONS: MAD represents a complex anatomical and functional entity associated with diagnostic challenges and rhythm abnormalities. Although the current indications for surgical treatment follow the recommendations for treatment of primary mitral regurgitation, early treatment may be important especially in patients with arrhythmias.
Authors 17
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Nikolaos E. Bonaros corresponding
Innsbruck Medical University · Universität Innsbruck · University Hospital Innsbruck
Affiliation as printed
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck , A-6020, Innsbruck,
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
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Innsbruck Medical University · Universität Innsbruck · University Hospital Innsbruck
Affiliation as printed
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck , A-6020, Innsbruck,
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
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Leiden University Medical Center
Affiliation as printed
Department of Cardiothoracic Surgery, Leiden University Medical Center , 2300, Leiden,
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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Leiden University Medical Center
Affiliation as printed
Department of Cardiology, Leiden University Medical Center , 2300, Leiden,
Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
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Hospital Universitari Germans Trias i Pujol
Affiliation as printed
Heart Institute, University Hospital Germans Trias i Pujol, and Center of Comparative Medicine and Bioimaging , 08916, Badalona,
Heart Institute, University Hospital Germans Trias i Pujol, and Center of Comparative Medicine and Bioimaging, Badalona, Spain
University Hospital Germans Trias i Pujol, and Center of Comparative Medicine and Bioimaging Heart Institute, , Badalona,
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Royal Papworth Hospital · Papworth Hospital NHS Foundation Trust
Affiliation as printed
Department of Cardiology, Royal Papworth Hospital Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus , CB2 0AY, Cambridge,
Department of Cardiology, Royal Papworth Hospital Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, UK
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Innsbruck Medical University · Universität Innsbruck · University Hospital Innsbruck
Affiliation as printed
Department of Radiology, University Hospital Innsbruck, Medical University of Innsbruck , A-6020, Innsbruck,
Department of Radiology, University Hospital Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
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Innsbruck Medical University · Universität Innsbruck · University Hospital Innsbruck
Affiliation as printed
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck , A-6020, Innsbruck,
Department of Cardiac Surgery, University Hospital Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
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Leipzig Heart Institute · University Hospital Leipzig
Affiliation as printed
University Department of Cardiac Surgery, Leipzig Heart Center , D-04289, Leipzig,
University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Affiliation as printed
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute , 20132, Milan,
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Affiliation as printed
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute , 20132, Milan,
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Innsbruck Medical University · Universität Innsbruck · University Hospital Innsbruck
Affiliation as printed
Department of Radiology, University Hospital Innsbruck, Medical University of Innsbruck , A-6020, Innsbruck,
Department of Radiology, University Hospital Innsbruck, Medical University of Innsbruck, Innsbruck, Austria
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Affiliation as printed
Department of Cardiovascular Surgery, Hospital Clínic , 08036, Barcelona,
Hospital Clínic Department of Cardiovascular Surgery, , Barcelona,
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Leiden University Medical Center
Affiliation as printed
Department of Cardiothoracic Surgery, Leiden University Medical Center , 2300, Leiden,
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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Affiliation as printed
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute , 20132, Milan,
Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Leipzig Heart Institute · University Hospital Leipzig
Affiliation as printed
University Department of Cardiac Surgery, Leipzig Heart Center , D-04289, Leipzig,
University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
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Affiliation as printed
Department of Cardiovascular Surgery, Campus Bad Neustadt , D-97616, Bad Neustadt/Saale,
Department of Cardiovascular Surgery, Campus Bad Neustadt, Bad Neustadt/Saale, Germany
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