Multimodality cardiovascular imaging in arrhythmic mitral valve prolapse: a state-of-the-art review from structural assessment to myocardial tissue characterization

Mitral valve prolapse (MVP) is a prevalent and traditionally benign heart valve disease; however, mounting evidence identifies a subset of patients at risk for malignant ventricular arrhythmias and sudden cardiac death. This narrative review critically examines the role of multimodality imaging in arrhythmic MVP, with an integrative overview of transthoracic echocardiography, cardiac magnetic resonance (CMR), computed tomography, and positron emission tomography. Particular attention is given to the complementary contribution of these modalities to structural, functional, and myocardial tissue characterization, while acknowledging their different levels of evidence and current clinical applicability. The specific added value of this review lies in organizing these imaging findings within a pathophysiological framework that links valve morphology and annular biomechanics to myocardial injury, diffuse fibrotic remodeling, focal replacement fibrosis, and arrhythmic vulnerability, rather than presenting each modality as an isolated diagnostic tool. Advanced CMR techniques, including native T1 and T2 mapping and extracellular volume quantification, are discussed as promising tools for detecting diffuse fibrosis and myocardial tissue characterization that may contribute to early myocardial remodeling. Genetic susceptibility is also considered as a potential modifier of phenotypic heterogeneity rather than as a routine component of current risk stratification. Overall, the reviewed literature supports an evolving framework for phenotypic characterization and mechanistic interpretation in arrhythmic MVP, while highlighting the need for further standardization, prospective validation, and cautious integration of advanced imaging biomarkers into clinical pathways.