Regional Variability of Cardiovascular Magnetic Resonance Imaging Access and Utilization in the United States.

BACKGROUND: Clinical guidelines and scientific data increasingly support the appropriate use of cardiovascular magnetic resonance (CMR) imaging. The extent of CMR adoption across the United States (U.S.) remains unclear. This observational analysis aims to capture CMR practice patterns in the U.S. METHODS: Commissioned reports from the Society of Cardiovascular Magnetic Resonance (SCMR), pre-existing survey data from CMR centers, and socioeconomic and coronary heart disease data from the Centers for Disease Control and Prevention were used. The location of imaging centers performing CMR was based on 2018 Medicare claims. Secondary analysis was performed on center-specific survey data from 2017-2019, which were collected by members of the SCMR U.S. Advocacy Subcommittee for quality improvement purposes. Correlation between the number of imaging centers billing for CMR services per million persons, socioeconomic determinants, and coronary heart disease epidemiology was determined. RESULTS: A total of 591 imaging centers billed the Center for Medicare & Medicaid Services for CMR services in 2018 and 112 (of 155) unique CMR centers responded to the survey. In 2018, CMR services were available in almost all 50 states. Minnesota was the state with the highest number of CMR centers per million Medicare beneficiaries (52.6 centers per million), and Maine had the lowest (4.4 per million). The total density of CMR centers was 16 per million for U.S. Medicare beneficiaries. Sixty-eight percent (83 of 112) of survey responders were cardiologists, and 28% were radiologists. In 72% of centers, academic healthcare systems performed 81-100% of CMR exams. The number of high-volume centers (>500 scans per year) increased by seven between 2017-2019. In 2019, 53% of centers were considered high-volume centers and had an average of 19 years of experience. Centers performing <50 scans had an of average 3.5 years' experience. Approximate patient wait time for a CMR exam was 2 weeks to 1 month. CONCLUSIONS: Despite increasing volume and availability in almost all 50 states, CMR access remains geographically variable. Advocacy efforts to improve access and innovations that reduce imaging time and exam complexity have potential to increase adoption of CMR technology.

Parachute Mitral Valve and Mid-Aortic Syndrome - Unusual Associations of Alagille Syndrome.

Background: Alagille syndrome (ALGS) is a multisystem disorder involving at least three systems among the liver, heart, skeleton, face, and eyes. Common cardiac associations include pulmonary artery stenosis/atresia, atrial septal defect (ASD), ventricular septal defect (VSD) and tetralogy of fallot (ToF). Coarctation of aorta (CoA), renal and intracranial arteries are commonly involved vessels in Alagille syndrome. We present two cases with rare cardiovascular manifestations of Alagille syndrome. Case description. Case 1: A 25-year-old female with a history of Alagille syndrome presented to the cardiologist office for progressive exertional dyspnoea, orthopnoea, and palpitations. She was tachycardiac on examination and had an apical diastolic rumble. A transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction (LVEF) of 60% and parachute mitral valve (PMV) with severe mitral stenosis. A transoesophageal echocardiogram (TOE) showed insertion of chordae into the anterolateral papillary muscle, severe mitral stenosis with a valve area of 0.7 cm. She was referred to a congenital heart disease specialist and underwent robotic mitral valve replacement with improvement in her symptoms. Case 2: A 27-year-old female with known Alagille syndrome and resistant hypertension presented to the cardiologist office due to progressive exertional dyspnoea for a year. She was hypertensive and had a new 2/6 systolic ejection murmur along the left upper sternal border. TTE revealed an LVEF of 60% and pulmonary artery pressure of 19 mmHg. A CoA was suspected distal to the left subclavian artery due to a peak gradient of 38 mmHg. Cardiac magnetic resonance (CMR) imaging ruled out CoA, and diffuse narrowing of the descending thoracic aorta measuring 13-14 mm in diameter was noted. The patient was referred to a congenital heart disease specialist for further management. Conclusion: PMV presenting as mitral stenosis and mid-aortic syndrome are not commonly described anomalies in association with Alagille syndrome. TTE, TOE and CMR played a key role in diagnosis and management of these patients. LEARNING POINTS: Alagille syndrome (ALGS) is a complex multisystem disorder involving the liver, heart, skeleton, face, and eyes. Cardiovascular involvement occurs in up to 95% of the patients.Common cardiac associations include pulmonary artery stenosis/atresia, atrial septal defect (ASD), ventricular septal defect (VSD) and tetralogy of fallot (ToF).A parachute mitral valve (PMV) presenting as mitral stenosis and mid-aortic syndrome is not commonly described anomalies in association with ALGS. Here, we present such rare cases.

Left Anterior Descending Coronary T-wave Inversion Pattern (Wellens' Syndrome) Associated with Myopericarditis and a Normal Left Coronary Artery.

Background: Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3 (may extend to involve all precordial and lateral limb leads - the type B Wellens' pattern). A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD). However, there are no reported cases of an association of a Wellens' EKG pattern with myopericarditis. Here, we present such a rare case. Case description: A thirty-one-year-old female with known essential hypertension and psoriatic arthritis presented with a constant, central chest pain radiating to the shoulders and back. The patient's physical examination was unremarkable at presentation other than elevated blood pressure at 170/68 mmHg. An EKG at presentation demonstrated deep symmetric T-wave inversions in anterolateral leads with elevated high-sensitivity troponin, and an elevated erythrocyte sedimentation rate. The patient was referred to the cardiac catheterisation laboratory for concerns of a Wellens' EKG pattern; however, invasive angiography demonstrated only obtuse marginal branch disease - no LAD disease was noted. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis of myopericarditis and absence of myocardial infarction. The patient was medically managed and discharged home in a stable condition. Conclusion: In literature and established clinical practice, the Wellens' EKG pattern is considered highly concerning for critical ostial/proximal LAD stenosis. However, we now propose that myopericarditis may be considered in a differential diagnosis for this EKG pattern. LEARNING POINTS: Wellens' syndrome is characterised by a history of chest pain with an abnormal electrocardiogram (EKG), demonstrating biphasic or deeply inverted T waves in leads V2-3.A Wellens' EKG pattern is considered highly specific for critical stenosis involving the ostial/proximal left anterior descending artery (LAD).Association of Wellens' pattern EKG has been described in association with various other pathologies; however, its association with acute myopericarditis has not been well described.

Novel use of dynamic MR hydrography to rule out esophageal perforation post atrial fibrillation ablation in a patient with anaphylaxis to gadolinium.

Esophageal thermal injury is one of the most devastating complications of atrial radiofrequency ablation, and its diagnosis can be challenging. In this report, we highlight the novel use of free water as a contrast material to better visualize the esophageal lumen in a patient with anaphylaxis to Iodinated contrast media and Gadolinium who recently underwent atrial fibrillation ablation. This becomes particularly handy in patients with contrast allergy, and further emphasizes the role of multimodality imaging.

Cardiovascular Testing in the United States during the COVID-19 Pandemic: Volume Recovery and Worldwide Comparison.

Purpose: To characterize the recovery of diagnostic cardiovascular procedure volumes in U.S. and non-U.S. facilities in the year following the initial COVID-19 outbreak. Materials and Methods: The International Atomic Energy Agency (IAEA) coordinated a worldwide study called the IAEA Noninvasive Cardiology Protocols Study of COVID-19 2 (INCAPS COVID 2), collecting data from 669 facilities in 107 countries, including 93 facilities in 34 U.S. states, to determine the impact of the pandemic on diagnostic cardiovascular procedure volumes. Participants reported volumes for each diagnostic imaging modality used at their facility for March 2019 (baseline), April 2020, and April 2021. This secondary analysis of INCAPS COVID 2 evaluated differences in changes in procedure volume between U.S. and non-U.S. facilities and among U.S. regions. Factors associated with return to prepandemic volumes in the United States were also analyzed in a multivariable regression analysis. Results: Reduction in procedure volumes in April 2020 compared with baseline was similar for U.S. and non-U.S. facilities (-66% vs -71%, P = .27). U.S. facilities reported greater return to baseline in April 2021 than did all non-U.S. facilities (4% vs -6%, P = .008), but there was no evidence of a difference when comparing U.S. facilities with non-U.S. high-income country (NUHIC) facilities (4% vs 0%, P = .18). U.S. regional differences in return to baseline were observed between the Midwest (11%), Northeast (9%), South (1%), and West (-7%, P = .03), but no studied factors were significant predictors of 2021 change from prepandemic baseline. Conclusion: The reductions in cardiac testing during the early pandemic have recovered within a year to prepandemic baselines in the United States and NUHICs, while procedure volumes remain depressed in lower-income countries.Keywords: SPECT, Cardiac, Epidemiology, Angiography, CT Angiography, CT, Echocardiography, SPECT/CT, MR Imaging, Radionuclide Studies, COVID-19, Cardiovascular Imaging, Diagnostic Cardiovascular Procedure, Cardiovascular Disease, Cardiac Testing Supplemental material is available for this article. © RSNA, 2023.

Mitral annular disjunction; how accurate are we? A cardiovascular MRI study defining risk.

Aims: Mitral Annular Disjunction (MAD) refers to embryologic fibrous separation between mitral annular ring and basal left ventricular myocardium. Since its original description, the role of MAD in arrhythmic mitral valve prolapse (MVP) has been the subject of active research. In this study we sought to assess prognostic and imaging characteristics of MVP patients with and without underlying MAD. Methods and results: Patients with posterior or bi-leaflet MVP were retrospectively identified via a review of all patients referred to our cardiac magnetic resonance (CMR) imaging laboratory from January 2015 to May 2022. MVP patients were further stratified by underlying MAD status. A total of 100 MVP patients undergoing CMR imaging (52 MVP patients with posterior MAD) were retrospectively identified with female comprising 55 % of the cohort. MVP patients with MAD were more likely to have an abnormal basal inferolateral/ papillary muscles LGE (51 % vs 21 %, p < 0.01). Posterior MAD longitudinal disjunction gap in 'mm' was a predictor of ventricular tachycardia (VT) [1.29, p = 0.01)]. Using ROC curve analysis, a disjunction gap of ≥ 4 mm was predictive of VT (AUC-0.71, p < 0.01), and incorporation of LGE in ROC model further improved AUC to 0.78 confirmed via Akaike information criterion (p < 0.01). Conclusion: Abnormal LGE involving basal inferolateral myocardium and papillary muscles may provide etiologic substrate for arrythmia in MVP patients.

A target definition based on electroanatomic maps for stereotactic arrhythmia radioablation.

PURPOSE: Identifying the target region is critical for successfully treating ventricular tachycardia (VT) with single fraction stereotactic arrhythmia radioablation (STAR). We report the feasibility of target definition based on direct co-registration of electroanatomic maps (EAM) and radioablation planning images. MATERIALS AND METHODS: The EAM consists of 3D cardiac anatomy representation with electrical activity at endocardium and is acquired by a cardiac electrophysiologist (CEP) during electrophysiology study. The CEP generates an EAM using a 3D cardiac mapping system anticipating radioablation planning. Our in-house software read these non-DICOM EAMs, registered them to a planning image set, and converted them to DICOM structure files. The EAM based target volume was finalized based on a consensus of CEPs, radiation oncologists and medical physicists, then expanded to ITV and PTV. The simulation, planning, and treatment is performed with a standard STAR technique: a single fraction of 25 Gy using volumetric-modulated arc therapy or dynamic conformal arc therapy depending on the target shape. RESULTS: Seven patients with refractory VT were treated by defining the target based on registering EAMs on the planning images. Dice similarity indices between reference map and reference contours after registration were 0.814 ± 0.053 and 0.575 ± 0.199 for LV and LA/RV, respectively. CONCLUSIONS: The quality of the transferred EAMs on the MR/CT images was sufficient to localize the treatment region. Five of 7 patients demonstrated a dramatic reduction in VT events after 6 weeks. Longer follow-up is required to determine the true safety and efficacy of this therapy using EAM-based direct registration method.

Worsening tricuspid regurgitation associated with permanent pacemaker and implantable cardioverter-defibrillator implantation: A systematic review and meta-analysis of more than 66,000 subjects.

BACKGROUND: Worsening tricuspid regurgitation (TR) after either permanent pacemaker (PPM) or implantable cardioverter-defibrillator (ICD) implantation is an emerging clinical challenge. Early recognition of this entity is essential in guiding treatment. OBJECTIVE: This meta-analysis was designed to identify the overall incidence and patient-specific predictors of TR post-device implantation. METHODS: We searched electronic databases from inception to January 2023 for published studies that reported the incidence of TR worsening post-device implantation. The log odds ratio (OR) was used to summarize group differences. RESULTS: Our analysis included 29 studies with 66,590 participants. Patients who underwent device implantation (n = 1008) were significantly more likely to develop worsening TR than controls who did not undergo device implantation (n = 58,605) (OR 3.18; P < .01). In a total of 7777 patients, the pooled incidence of at least 1-grade worsening of TR post-device implantation was 24%. Worsening TR post-device implantation significantly increases mortality (hazard ratio 1.42; P = .02). Larger right atrial area (OR 1.11; P < .01) is significantly associated with an increased risk of worsening TR post-device implantation, while male patients are less likely to develop this complication than female patients (OR 0.74; P < .01). Importantly, there is no statistically significant difference between the type of implanted device (ICD vs PPM) and post-device implantation TR. Further, right ventricular dysfunction, pulmonary artery pressure, baseline mitral regurgitation, left ventricular ejection fraction, baseline atrial fibrillation, and age have no association with worsening TR post-device implantation. CONCLUSION: A substantial number of patients undergoing PPM or ICD implantation are at an increased risk of worsening TR. Importantly, in this largest review to date incorporating more than 66,000 subjects, worsening TR significantly increases mortality by greater than 140%, accordingly deserving more recognition and clinical attention in the current era.

The sine transform is the sine qua non of the pulmonary and systemic pressure relationship.

Assessment of therapeutic interventions in patients with pulmonary arterial hypertension (PAH) suffers from several commonly encountered limitations: (1) patient studies are often too small and short-term to provide definitive conclusions, (2) there is a lack of a universal set of metrics to adequately assess therapy and (3) while clinical treatments focus on management of symptoms, there remain many cases of early loss of life in a seemingly arbitrary distribution. Here we provide a unified approach to assess right and left pressure relationships in PAH and pulmonary hypertension (PH) patients by developing linear models informed by the observation of Suga and Sugawa that pressure generation in the ventricle (right or left) approximately follows a single lobe of a sinusoid. We sought to identify a set of cardiovascular variables that either linearly or via a sine transformation related to systolic pulmonary arterial pressure (PAPs) and systemic systolic blood pressure (SBP). Importantly, both right and left cardiovascular variables are included in each linear model. Using non-invasively obtained cardiovascular magnetic resonance (CMR) image metrics the approach was successfully applied to model PAPs in PAH patients with an r2 of 0.89 (p < 0.05) and SBP with an r2 of 0.74 (p < 0.05). Further, the approach clarified the relationships that exist between PAPs and SBP separately for PAH and PH patients, and these relationships were used to distinguish PAH vs. PH patients with good accuracy (68%, p < 0.05). An important feature of the linear models is that they demonstrate that right and left ventricular conditions interact to generate PAPs and SBP in PAH patients, even in the absence of left-sided disease. The models predicted a theoretical right ventricular pulsatile reserve that in PAH patients was shown to be predictive of the 6 min walk distance (r2 = 0.45, p < 0.05). The linear models indicate a physically plausible mode of interaction between right and left ventricles and provides a means of assessing right and left cardiac status as they relate to PAPs and SBP. The linear models have potential to allow assessment of the detailed physiologic effects of therapy in PAH and PH patients and may thus permit cross-over of knowledge between PH and PAH clinical trials.

Effectiveness of levosimendan and role of cardiac magnetic resonance in cardiogenic shock due to COVID-19 related lymphocytic myocarditis in the course of viral sepsis.

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.

Prognostic role of pulmonary hemodynamics before transcatheter aortic valve replacement among patients with severe aortic stenosis.

BACKGROUND: Pulmonary hypertension (PH) frequently co-exists in patients with severe aortic stenosis (AS). In this study, we sought to identify the implications of invasive pulmonary hemodynamics on major adverse cardiac events (MACE), biventricular function and NYHA functional class after transcatheter aortic valve replacement (TAVR). METHODS: Invasive hemodynamics via right heart catheterization (RHC) were performed pre-TAVR. Patients were stratified per mean PA pressure (mPAP), diastolic pulmonary gradient (DPG) and pulmonary vascular resistance (PVR), and followed at 1-month and 1-year intervals up to 6 years. MACE outcomes included cardiovascular death and heart failure hospitalizations post-TAVR. RESULTS: Among 215 patients, Kaplan-Meir estimates demonstrated an increased 1-year risk of MACE from 8% among those without pre-TAVR PH to 27% among patients with pre-existing PH. Specifically, the MACE risk was 32% among PH patients with PVR ≥ 3WU (p = .04) and 53% among PH patients with DPG ≥ 7 mm Hg (p < .01). On univariate Cox regression, RV stroke work index (RVSWI) (HR,1.02; p = .02), and pulmonary hemodynamic index (PHI) (HR,1.27; p = .047) were identified as additional predictors of MACE post-TAVR. On multivariable Cox regression analysis, SvO2 (HR, 0.95; p = .01) and PVR (HR, 1.2; p = .04) were demonstrated as predictive of MACE post-TAVR. A significant improvement in LVEF (2-Factor ANOVA, p < .01) and RV fractional area change (RVFAC%) (p < .01) was noted as assessed at baseline, 1-month and 1-year follow up post-TAVR. There was a significant interaction between pre-TAVR PH status and time post procedure with respect to NYHA functional class (p = .03), that is, the manner and degree of change in NYHA class over time depended on pre-TAVR PH status. CONCLUSIONS: Defining invasive pulmonary hemodynamics, such as mPAP, PVR, and DPG among patients with severe AS undergoing TAVR has significant prognostic implications. Routine risk stratification by utilizing invasive hemodynamics can better identify patients who will have functional improvement and improved outcomes post-TAVR.

Left ventricle accessory antero-septal papillary muscle: an echocardiography and cardiac MRI case-series report.

Background. We studied by means of echocardiography and cardiac MRI (CMR) the occurrence of an accessory papillary muscle that unites mostly the left ventricle (LV) apex with the basal antero-septum in the immediate vicinity of left ventricle outflow tract (LVOT) in patients with and without hypertrophic cardiomyopathy (HOCM). Methods. We included all good quality echocardiography and CMR studies as reviewed by two cardiologists and assessed the occurrence of a contractile papillary muscle situated between the LV apex and antero-septum. Results. A contractile accessory papillary muscle situated between the LV apex and the anteroseptum was seen in 100% of HOCM patients and 62% of control patients (p=0.05) in the CMR images acquired from a total of 9 HOCM and 13 control patients. The same structure was observed in 241 patients representing 69.5% of all-comers echocardiography studies. The age was 69 ± 17 years on average in the echocardiography arm, patients harboring the antero-septal accessory muscle being older (71.6 + 15.7 years old vs 63.5 ± 18.1 for those without, p=0.0005). We exemplify this structure by parasternal long axis still echocardiography images and clips from 24 patients and CMR SSFP still images and a clip from two HOCM patients and one control. Conclusion. A contractile accessory papillary muscle was observed in more than half of the all-comer echocardiography studies, and in all HOCM patients in the CMR arm. Further research is needed to fully characterize the anatomical and physiological significance as well as the possible structural interventional consequences of this structure attaching in the immediate vicinity of the LVOT in HOCM and control patients.

Accordion sign in COVID 19 related acute myocarditis, an old sign for a novel context? A cardiac magnetic resonance case series report study.

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.

When it's neighbor's fault, a complicated ascending aortic aneurysm mimicking pulmonary embolism: A case report.

Thoracic aortic aneurysms represent a potentially life-threatening disease with increasing prevalence, probably related to the increasing mean age of the global population; the complications of thoracic aortic aneurysms can show multiple modes of presentation in the acute phase based on various factors, including the involvement of the structures with which the aneurysm is in close anatomical relationship. With this case report we want to show how it is possible that a complicated ascending aortic aneurysm can mimic an acute pulmonary embolism/acute cor pulmonale in the acute phase; the earliest possible differential diagnosis between pulmonary embolism and acute aortic disease is of crucial importance due to the opposite implications that the treatment of these two diseases have. .

Acute Severe Aortic Regurgitation From Catastrophic Pannus Obstruction in a Patient With Mechanical Aortic Valve Replacement.

A 69-year-old woman with a mechanical aortic valve presented with decompensated heart failure. Emergent echocardiogram and fluoroscopy demonstrated acute aortic regurgitation due to a dysfunctional mechanical aortic valve and non-obstructive coronary disease. An emergent valve replacement was performed confirming a fixed-open valve with pathology demonstrating obstructive pannus formation without thrombosis or vegetation.

Tricuspid annular disjunction can be isolated and even arrhythmogenic. A cardiac magnetic resonance study.

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.