Gerald M. Lawrie

BACKGROUND: Mitral valve prolapse (MVP) is a common cardiac condition that is generally benign, yet a subset of affected patients develop malignant ventricular arrhythmias and sudden cardiac death. Female sex and myocardial fibrosis detected by late gadolinium enhancement on cardiovascular magnetic resonance imaging have been proposed as risk factors though their independent contributions to arrhythmic risk remain uncertain. METHODS: We conducted a prospective cohort study of 550 consecutive patients with MVP referred for cardiovascular magnetic resonance at a tertiary academic center between May 2008 and December 2021. Patients with potential confounders, including coronary artery disease, cardiomyopathy, infiltrative disease, or prior cardiac surgery, were excluded. The primary end point was a composite arrhythmic outcome comprising sudden cardiac death, aborted sudden cardiac arrest, and symptomatic sustained or inducible ventricular tachycardia or ventricular fibrillation leading to implantable cardioverter defibrillator placement or ventricular ablation at an MVP-related scar site. RESULTS: Among the 550 patients (median age, 62 [interquartile range, 52–71] years; 50% women), late gadolinium enhancement (LGE) was present in 210 (38%). Over a median follow-up of 4.4 years (interquartile range, 2.8–7.1; 2700 patient-years), 48 patients (8.7%) reached the primary end point. On univariable analysis, both female sex (hazard ratio, 3.33 [95% CI, 1.72–6.44]; P P P <0.001). CONCLUSIONS: In a large prospective cardiovascular magnetic resonance cohort of patients with MVP, female sex and myocardial fibrosis were each independently associated with life-threatening arrhythmic events. Their combination identified a subgroup at particularly elevated risk, highlighting the importance of integrating sex-specific factors and myocardial tissue characterization into MVP risk stratification strategies.

Spontaneous coronary sinus thrombosis (CST) is an extremely rare occurrence. Most cases are iatrogenic and related to right heart instrumentation, due to either central line placement or electrophysiology procedures such as pacemaker insertion that causes direct damage to the endothelial lining. The course can be insidious and may result in a fatal outcome. Diagnosis of CST is challenging, and the syndrome often goes unrecognized. However, in the current era of multimodality imaging, it is possible that this condition will be recognized in more patients. Herein, we present a patient with spontaneous coronary sinus thrombosis that was diagnosed using multimodality imaging and thereafter successfully managed.

Cor triatriatum dexter is a rare congenital heart defect with a varied clinical presentation ranging from asymptomatic to right heart failure. Accurate diagnosis is imperative as it may affect clinical decision making. We present a multimodality imaging assessment of cor triatriatum dexter in a 70-year-old woman with severe tricuspid regurgitation.

The treatment of drug-refractory chronic ventricular tachycardia (VT) has undergone a revolution over the last 50 years. We now have automatic implantable cardioverter defibrillator therapy with pace-terminating capabilities, and catheter ablation of VT has refined mapping and improved methods of lesion generation. Between 1980 and 1993, Houston Methodist Hospital became a leader in the diagnosis and surgical ablation of VT and other arrhythmias. This is a brief account of that period and some of the experiences and lessons that have led to significant advances used today.

Purpose of review: Mitral repair is the best treatment for degenerative mitral regurgitation. Many patients are referred too late for optimal outcomes. The US repair vs. replacement rate is only 60–80%, at a time when the inferiority of replacement has been established. Therefore, widely used traditional techniques of repair are being reappraised. Recent findings: Identification of risk factors predictive of poor early and late outcome have improved timing for surgical referral. Composite risk scores have been developed. Novel echocardiographic, cardiac MRI, and molecular level risk factors could improve timing. Analysis of factors contributing to low repair rates is also of critical importance. The role of institutional and surgeon volumes have been identified. More detailed data on the importance of dynamic function of the mitral valve have led to improved repair techniques such as intraoperative simulation of end diastole and early systole, use of expanded polytetrafluoroethylene neochords instead of leaflet resection, and dynamic instead of rigid annuloplasty. Summary: Our perception of mitral regurgitation has changed from a seemingly simple condition to one of considerable complexity at multiple levels. National guidelines should be studied and followed.