ECG, an essential tool to guide arrhythmic mitral valve prolapse diagnosis

A 35-year-old man was referred for cardiac check-up because of repetitive reflex syncope. He underwent a tilt-test challenge without syncope provocation. The ECG at the begginning of the test showed sinus rythm with polimorphic premature ventricular contractions (PVC), with right bundle branch block morphology (Fig.1). There were T wave inversion in inferior leads with no other repolarisation abnormalities. An echocardiogram was performed and it showed bileaflet mitral valve prolapse with moderate regurgitation. Left atrium was mildly dilated and left ventricular ejection fraction was preserved. Afterwards, the patient underwent prolonged Holter monitoring with frequent pleomorphic PVC’s (7%), and three non-sustained runs of ventricular tachycardia. After that, a cardiac magnetic resonance was performed showing mitral annular disjunction in telesystole, and late gadolinium enhancement in posteromedial papilary muscle, and all over mitral annulus. Because all of these findings, diagnosis of arrythmic mitral valve prolapse was done. The patient underwent implantable loop recorder implantation, and begun treatment with low-dose betablockers. It was decided that ICD will be considered depending on the ILR findings. Electrocardiogram is an essential tool which can even guide or suggest the diagnosis even in the absence of cardiac imaging. ECG is might!