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Mitral valve prolapse is a common valve disorder that usually has a benign prognosis unless there is significant regurgitation or LV impairment. However, a subset of patients are at an increased risk of ventricular arrhythmias and sudden cardiac death, which has led to the recognition of "arrhythmic mitral valve prolapse" as a clinical entity. Emerging risk factors include mitral annular disjunction and myocardial fibrosis. While echocardiography remains the primary method of evaluation, cardiac magnetic resonance has become crucial in managing this condition. Cine magnetic resonance sequences provide accurate characterization of prolapse and annular disjunction, assessment of ventricular volumes and function, identification of early dysfunction and remodeling, and quantitative assessment of mitral regurgitation when integrated with flow imaging. However, the unique strength of magnetic resonance lies in its ability to identify tissue changes. T1 mapping sequences identify diffuse fibrosis, in turn related to early ventricular dysfunction and remodeling. Late gadolinium enhancement sequences detect replacement fibrosis, an independent risk factor for ventricular arrhythmias and sudden cardiac death. There are consensus documents and reviews on the use of cardiac magnetic resonance specifically in arrhythmic mitral valve prolapse. However, in this article, we propose an algorithm for the broader use of cardiac magnetic resonance in managing this condition in various scenarios. Future advancements may involve implementing techniques for tissue characterization and flow analysis, such as 4D flow imaging, to identify patients with ventricular dysfunction and remodeling, increased arrhythmic risk, and more accurate grading of mitral regurgitation, ultimately benefiting patient selection for surgical therapy. [ABSTRACT FROM AUTHOR]

COVID-19 and sepsis pose great challenges to clinicians and growing evidence is demonstrating links between the two conditions. Both can be complicated by acute heart failure. The use of levosimendan in patients with ventricular dysfunction during COVID-19 infection and sepsis has very little evidence. A 46-year-old, hypertensive and obese patient was admitted for severe left ventricular failure and shock during sepsis following a COVID-19 infection. The patient was treated first with norepinephrine, which was partially effective, then with the addition of levosimendan as a continuous 24 hours infusion. Vital signs and echocardiographic systolic performance indices, such as FE, SVi, CI, dP/dT, TAPSE, and tricuspid S-wave velocity, as well as diastolic function, were recorded at access, 12 and 24 hours. After initiation of levosimendan, a rapid improvement in vital signs and systolic and diastolic performance indices was observed, not depending on changes in preload, afterload, and inflammatory status. Blood cultures were negative for the presence of bacteria, thus defining the picture of likely viral sepsis. Cardiac magnetic resonance was determinant, showing a picture of myocarditis sustained by immune processes rather than direct viral injury, which was confirmed by endomyocardial biopsy. In conclusion, this case highlights the efficacy of levosimendan in acute heart failure complicated by shock due to COVID-19-related myocarditis and concomitant sepsis and confirms cardiac magnetic resonance as the gold standard for the diagnosis of myocardial inflammatory disease. To the best of our knowledge, this is the first documented case of effective use of levosimendan in this context. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The COVID-19 pandemic is related to a higher incidence of myocarditis; we present a case series of seven patients, admitted with COVID-19 related acute myocarditis, evaluated with cardiac magnetic resonance imaging, showing an altered profile of the free wall of the right ventricle, no longer present after six months follow-up. MATERIALS AND METHODS: Seven patients have been evaluated for COVID-19 related acute myocarditis, all patients have been evaluated with cardiac magnetic resonance imaging both in the acute setting and after six months follow-up. RESULTS: In the acute phase, myocarditis was confirmed in keeping with the current diagnostic criteria. In five out of seven cases, the presence of a crinkling profile of the free wall of the right ventricle was observed; at six months follow up, remission in four out of the five cases and a significant reduction in the remaining case, of the previously described findings, was observed. CONCLUSIONS: Crinkling appearance in the profile of the free wall of the right ventricle, detectable with cardiac magnetic resonance imaging, might represent a morphological feature present in the acute setting of COVID-19 related myocarditis; several underlying physiopathological mechanisms are conceivable. Further studies are needed to confirm this correlation, define the underlying mechanisms and the prognostic implication related to it. This is the first report in the literature that has considered such findings to the best of our knowledge. [ABSTRACT FROM AUTHOR]

Mitral annular disjunction is related to increased arrhythmogenic risk; in a certain percentage of cases, mitral annular disjunction is associated with tricuspid annular disjunction. While the prognostic implications of mitral annular disjunction have been well established, there is still little data to define this aspect regarding the tricuspid annular disjunction. We present a case of a patient admitted for life-threatening ventricular arrhythmias that occurred during endurance sporting activity, who was found to have isolated tricuspid annular disjunction, not associated with mitral annular disjunction. Based on several factors, including the morphology and axis of QRS of the ventricular arrhythmic activity, and its behavior, including the response to antiarrhythmic treatment, and in keeping with the finding of edema and late gadolinium enhancement at the basal segment of the right ventricle free wall on cardiac magnetic resonance imaging, a direct relation between tricuspid annular disjunction and ventricular arrhythmias was highly conceivable. Control after three months showed almost complete remission of the previously described and persistence of LGE at the level of the basal segment of the free wall of the right ventricle, so giving strength to the hypothesis of an event related to increased acute RV free wall stress, secondary to high-intensity physical activity, established on a framework of chronic wall stress, as represented by LGE, similarly to what happens for mitral valve prolapse. To the best of our knowledge, this is the first case of a legitimately conceivable direct relation between tricuspid annular disjunction and ventricular arrhythmias. [ABSTRACT FROM AUTHOR]