Left ventricular false tendons as incidental findings in a case of sudden cardiac death: What is their role?

Sudden death (SD) can be defined as the unexpected natural death of a healthy individual occurring within the first hour after the onset of symptoms or, if death is unwitnessed, within 24 h of the victim being seen in a healthy state. In people younger than 35 yo, when the cause of SD is" cardiac" (sudden cardiac death-SCD), it is mainly due to cardiomyopathies and channelopathies. Among the predictors of SCD, obesity (a well-established independent risk factor for cardiovascular diseases) has been found to increase arrhythmic risk (i.e., every 5-unit increment in BMI confers a 16 % higher risk of SCD). We herein describe an autoptic case of an obese 32-year-old woman (BMI of 49.9), who was discovered deceased in her bed at home. Interestingly, at the heart examination, the presence of an abnormality in the tendon apparatus of the anterior mitral valve leaflet was observed. In fact, an accessory tendon chord connecting the apex of the leaflet to the distal third of the antero-lateral papillary muscle was found in addition to an unusual retiform appearance ("web-like") of the whole mitral valve tendon apparatus. At histological examination of the ventricular myocardium, foci of confluent interstitial and perivascular myocardiosclerosis, along with perivascular fibrosis of coronary intramyocardial were observed. According to the literature, the valvular findings observed could plausibly account for the cause of death. In particular, a fatal arrhythmia due to the above-described tendons apparatus abnormality may developed. Nevertheless, obesity, which is a well-established risk factor for adverse cardiovascular events, may have contributed independently of the accessory chordal tendon. This case underscores the intricate interplay between the existence of left ventricular false tendons (LVFTs) and an elevated risk of ventricular tachycardia. From a speculative point of view, an LVFT may induce mechanical stretch in the interventricular septum, leading to heightened automaticity and triggering premature ventricular beats or arrhythmias. Comprehensive awareness of these structural anomalies and their morphological attributes is crucial for establishing correlations with potentially fatal arrhythmias and for formulating targeted preventive interventions.