Is it all about mitral annular disjunction?

This commentary refers to ‘Mitral annular disjunction and mitral valve prolapse: long-term risk of ventricular arrhythmias after surgery’, by K. Lodin et al., https://doi.org/10.1093/eurheartj/ehaf195. We truly enjoyed the article by Lodin et al.1 about the effect of pre-operative mitral annular disjunction (MAD) on ventricular arrhythmias (VAs) following either mitral valve repair or replacement for severe mitral regurgitation due to mitral valve prolapse (MVP). As explained thoroughly in the accompanying editorial by van Kampen et al.,2 MAD augments abnormal valvular-myocardial mechanics by increasing systolic annular expansion and the traction on the myocardium by the prolapsing leaflets. It is reasonable to assume that surgical correction of MAD would resolve MAD-related traction and the arrhythmogenicity associated with such abnormal mechanics. However, the current study suggests that pre-operative MAD may be associated with a higher risk of VAs despite its surgical correction with annuloplasty or valve replacement. We commend the authors for creating the largest surgical MVP cohort with detailed characterization of MAD (excluding ‘pseudo-MAD’) and long-term outcomes. However, we would exercise caution in the interpretation of their data.