Is true -MAD what we are truly looking for in arrhythmic risk stratification?

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 and the discussion piece ‘Mitral annular disjunction and ventricular arrhythmias after mitral valve surgery: true, longer, inferolateral disjunctions matter’, by K. Lodin et al., https://doi.org/10.1093/eurheartj/ehag243. In the study by Lodin et al.1 patients with mitral valve prolapse (MVP) and true inferolateral mitral annular disjunction (MAD) undergoing mitral valve surgery retained a three-fold higher risk of ventricular arrhythmias (VAs) compared with patients without MAD, suggesting that the presence of true-MAD might represent a risk marker for VAs, despite surgical resolution of the anatomic disjunction. Accumulating evidence suggests that the arrhythmic relevance of MAD is not defined by its mere anatomical presence, but by its mechanical consequences within the MVP complex.2,3 A MAD of limited longitudinal extent is common when assessed with advanced imaging modalities,3 up to 96% of all-comer patients,4 Table 1. While inferolateral MAD is less frequent,3 agreement between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) for MAD detection is low in cases of limited extent.5 In two independent cohorts, the prevalence of inferolateral true-MAD was 38% and 7% by CMR and TTE, respectively.6,7 Since systolic MAD is greater than diastolic MAD, with the latter measuring