Cardiac Magnetic Resonance in the Evaluation of Mitral Valve Prolapse: A Systematic Review

This thesis presents a PRISMA-conformant systematic review that examines the role of cardiovascular magnetic resonance (CMR) in the evaluation of degenerative mitral valve prolapse (MVP), treating MVP as a coupled valvulo-myocardial syndrome rather than a purely valvular disorder defined only by the severity of mitral regurgitation (MR). The review appraises how CMR contributes across four linked domains, namely MR quantification, myocardial tissue characterization using late gadolinium enhancement (LGE) and parametric mapping, geometric assessment of mitral annular disjunction (MAD), and evaluation of basal mechanics and strain, and it relates these imaging findings to clinical outcomes with particular emphasis on ventricular arrhythmias. A structured search of major bibliographic databases and trial registries was performed up to September 2025 and included studies of adults with degenerative MVP assessed by CMR. After screening the literature, sixteen studies with approximately 1,300 participants were included. The evidence was synthesized primarily with a narrative approach aligned to SWiM guidance, complemented by meta-analysis where feasible. Across the included evidence, focal myocardial fibrosis detected by LGE emerged as the most informative single CMR marker for complex ventricular arrhythmias, particularly when enhancement involved the papillary muscles and the basal inferolateral left ventricular wall. In pooled diagnostic-accuracy synthesis, LGE demonstrated substantial discriminative performance, with HSROC AUC around 0.83 and a log-odds ratio around 2.1. Importantly, the absence of LGE did not imply the absence of risk, because elevated mapping indices such as native T1 and extracellular volume fraction were reported to extend risk detection toward diffuse interstitial remodeling in some LGE-negative patients. In the geometric and mechanical domains, MAD showed only moderate association with arrhythmias when it was reported dichotomously as present or absent, whereas continuous, sector-specific and phase-aware measurements were more coherent with abnormalities in basal strain, strain dispersion, and tissue remodeling along the posterolateral stress axis. Global volumetric markers such as LVEDVi and LVEF showed limited discriminative value for arrhythmic risk, reinforcing that a purely chamber-based phenotype is often insufficient. Overall, the thesis concludes that CMR enables a multi-domain phenotype of degenerative MVP that integrates load (MR burden), substrate (LGE and mapping), geometry (MAD), and mechanics (basal strain signatures). A composite interpretation that reports these pillars together appears more faithful for risk stratification than relying on any single marker, while translation into routine clinical decision-making requires standardized acquisition and analysis, harmonized outcome definitions, and prospective validation.