Objectives: Pronounced mitral annular disjunction (pMAD ≥8 mm) in myxomatous mitral valve disease has been associated with ventricular arrhythmias in selected cohorts, whereas minor degrees of mural separation are frequently observed in structurally normal hearts. Its clinical relevance after mitral valve surgery remains unclear. We investigated whether pMAD is associated with postoperative symptom burden and rhythm outcomes. Methodsv: In this retrospective cohort with prospective follow-up, 246 adults undergoing mitral valve surgery for Barlow’s disease were classified intraoperatively as pMAD (≥8 mm) or non-pMAD (<8 mm). The primary end point was patient-reported postoperative palpitations. Propensity score–based inverse probability weighting was applied to adjust for baseline differences. Structured follow-up in pMAD patients included transthoracic echocardiography (TTE) and 24-hour Holter monitoring. Results: pMAD was present in 103 patients (41.9%). Surgery effectively reduced disjunction distance. At follow-up, palpitations were more frequent in pMAD compared with non-pMAD patients (40.8% vs 18.9%, P = .011), remaining significant after adjustment. In the pMAD follow-up cohort, atrial fibrillation prevalence decreased significantly after surgery. Holter monitoring did not demonstrate sustained malignant arrhythmias. Survival and major adverse events were comparable between groups. Conclusions: After mitral valve surgery for Barlow’s disease, pMAD is independently associated with increased postoperative palpitations despite anatomical correction. This association was not accompanied by excess malignant arrhythmias or adverse clinical end points, suggesting persistent symptom susceptibility rather than overt electrical instability.

Background: Mitral regurgitation due to Barlow’s disease remains surgically demanding. Despite widespread experience, consensus is lacking on whether the Alfieri repair can serve as a deliberate and durable rather than a rescue strategy in this complex pathology. Methods: We retrospectively analyzed patients undergoing mitral valve repair due to severe mitral regurgitation resulting from Barlow’s disease using either the Alfieri or Neochordae repair techniques. Patients received a uniform semi–rigid annuloplasty ring, while leaflet resection and concomitant coronary or aortic procedures were excluded. Results: Baseline demographics and echocardiography were broadly comparable. Perioperative mortality was 0% in both cohorts, with similarly low rates of major complications. Aortic cross–clamp time was significantly shorter with Alfieri repair (p < 0.001). No relevant postoperative transmitral gradient or systolic anterior motion occurred. At a mean follow–up of 4.2 years, more–than–moderate MR was observed in one patient per group (Alfieri 2.4% vs. Neochordae 1.2%). At 10 years, the cumulative incidence of more–than–moderate mitral regurgitation and redo mitral surgery was similarly low between techniques (p = 0.810 and p = 0.460). Most patients were NYHA class I–II at last follow–up, demonstrating improved functional status. Echocardiography showed left ventricular reverse remodeling without intergroup differences. Conclusions: These data indicate that the Alfieri approach provides durable competence and hemodynamic safety comparable to the Neochordae technique while reducing cross–clamp time, supporting its use as a deliberate strategy rather than a bailout in anatomically suitable valves.

Mitral annular disjunction (MAD) has been associated with ventricular arrhythmias in mitral valve prolapse, while postoperative ventricular arrhythmia burden remains incompletely characterized. We aimed to assess objective ventricular arrhythmia burden after mitral valve surgery in patients with and without pronounced MAD (pMAD). In this retrospective single-center cohort with cross-sectional postoperative rhythm assessment, patients undergoing mitral valve surgery for Barlow’s disease between 2014 and 2023 were stratified by intraoperative transesophageal echocardiography into pMAD (≥8 mm) and non-pMAD (<8 mm). All patients were invited to structured postoperative follow-up, including 24-h Holter monitoring at variable time points after surgery. Valid recordings were available in 126 of 246 patients (51.2%; 66 pMAD, 60 non-pMAD). Patients with pMAD had a significantly higher ventricular ectopic burden than those without pMAD (median 20.1 vs. 5.5 VES/h; p = 0.005). Non-sustained ventricular tachycardia was documented exclusively in the pMAD group (15.2% vs. 0%; p = 0.001). After multivariable adjustment, pMAD remained associated with high ventricular ectopic burden (OR 3.38, 95% CI 1.32–8.64; p = 0.011). These findings identify pMAD as a marker of increased postoperative ventricular arrhythmia burden after mitral valve surgery for Barlow’s disease.