case_images: PMC11004239_01
case_images: (A,B) Mitral annular disjunction (MAD) demonstrated by 4D and 2D transthoracic echocardiography (TTE), 12 mm of distance from posterior left ventricular (LV) wall, indicated with yellow line, and (C,D) extent of disjunction arc seen with two different orthogonal volume rendering views, indicated with yellow arrows.
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case_images: F1
case_images: TTE revealed severely dilated left heart chambers (4D left ventricular end-diastolic volume (LVEDV) = 218 ml, left atrial volume index (LAVI) >48 ml/m2) with an LVEF of 57%, bileaflet prolapse of the mitral valve, severe MR [effective regurgitant orifice area (EROA) 60 mm2, regurgitant volume (RV) 117 ml], and a 12 mm displacement of the hinge point of the mitral annulus from the posterior ventricular wall (Figures 1A,B). Further complete 3D-TTE analysis of the patient was performed to demonstrate the imaging findings of MAD syndrome (Figures 1C,D). Volume rendering views can reveal the actual part of the free posterior wall of the left ventricle that is separated from the annulus and the atrium (Figures 1C,D).
case_images: (A) Monomorphic and polymorphic ventricular tachycardia in 24 h ambulatory electrocardiogram (ECG) and (B) cardiac magnetic resonance imaging (CMR) with fibrosis detection of the basal inferolateral wall.
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case_images: F2
case_images: A previous CMR examination of the patient had reported LV dilatation with almost identical volumes and EF to TTE (EDV = 217 ml, EF = 59%), the presence of MAD of 10 mm displacement, and the presence of myocardial fibrosis of the basal inferolateral wall (Figure 2). Due to our protocol for patients with syncope, we performed a 24 h ambulatory electrocardiogram (ECG) that revealed episodes of monomorphic and polymorphic non-sustained ventricular tachycardia (Figure 2).
case_images: Four-dimensional strain analysis showing abnormal values of circumferential, area, and radial strain of the basal inferolateral wall.
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case_images: F3
case_images: The segmental radial strain was measured at 35% (normal values at 43.2 +- 4.5%), area strain at 24% (-36.5 +- 3.9%) (with adjacent segmental values of -47 and -56%), and circumferential strain at 18% (-30.3 +- 4.0%), while the longitudinal strain was preserved at -22% (-21 +- 0.6%) due to the hyperdynamic motion of the basal posterior wall (Figure 3).
case_images: Diastolic (A) and systolic (B) mitral valve quantification (MVQ) models showing the dynamic changes and the systolic expansion and flattening of the mitral annulus.
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case_images: F4
case_images: Meanwhile, the annulus height decreased from 11.4 cm to 7.0 cm (Figure 4).