MITRAL ANNULAR DISJUNCTION IN ATHLETES: AN UNDERRECOGNIZED ARRHYTHMOGENIC SUBSTRATE AT THE INTERFACE OF SPORTS CARDIOLOGY AND SUDDEN CARDIAC DEATH PREVENTION

Background: Mitral annular disjunction (MAD) is a structural abnormality of the mitral valve apparatus characterized by atrial displacement of the leaflet hinge point away from the left ventricular myocardium. Once considered an incidental finding, MAD is now recognized as a component of the arrhythmic mitral valve prolapse phenotype and a potential substrate for ventricular arrhythmias and sudden cardiac death, particularly in physically active individuals. Objectives: To summarize current evidence regarding the anatomy, epidemiology, arrhythmogenic mechanisms, multimodality imaging, risk stratification, and management of MAD, with emphasis on its relevance in athletes. Methods: A narrative review of the literature was performed using PubMed/MEDLINE and major cardiology and sports medicine journals. Publications from 1999 to 2024 were reviewed using the terms “mitral annular disjunction”, “arrhythmic mitral valve prolapse”, “athlete”, “exercise”, “sudden cardiac death”, “eligibility”, and “return to play”. Priority was given to recent guidelines, expert consensus documents, systematic reviews, large cohort studies, and landmark publications. Results: Physiological cardiac remodeling in athletes may obscure the diagnosis of MAD, while exercise-related hemodynamic and autonomic changes may facilitate ventricular arrhythmias in susceptible individuals. Current recommendations support individualized risk assessment and shared decision-making rather than universal sports restriction. Conclusions: MAD should be considered during cardiovascular evaluation of athletes with bileaflet mitral valve prolapse, unexplained ventricular arrhythmias, or a family history of sudden cardiac death. Further studies are needed to establish athlete-specific risk stratification and long-term management strategies.