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However, despite advances in mitral repair, the arrhythmic substrate associated with MAD remains insufficiently addressed in current surgical paradigms.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>A systematic search of PubMed and Google Scholar (2000\u20132025) was conducted using keywords including \u201cmitral annular disjunction,\u201d \u201cmitral regurgitation,\u201d \u201carrhythmic mitral valve prolapse,\u201d and \u201cmitral valve surgery.\u201d Of 264 records screened, 41 peer\u2011reviewed articles, prioritizing high\u2011impact registries and surgical cohorts, were selected for synthesis.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>MAD is associated with paradoxical annular curling and traction\u2011related myocardial remodeling, which may contribute to fibrosis through pathological stretch. Observational studies suggest that higher\u2011risk features\u2014such as extensive MAD (\u2265\u20095\u00a0mm, particularly\u2009\u2265\u20098.5\u00a0mm), late gadolinium enhancement, or syncope\u2014are linked to increased arrhythmic vulnerability. Although modern repair techniques can eliminate anatomical MAD, pre\u2011existing substrate abnormalities may persist, and ventricular arrhythmias can still occur after technically successful repair.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The extent of disjunction and the presence of associated substrate abnormalities appear to influence long\u2011term rhythm stability. A conceptual, hypothesis\u2011generating framework that integrates structural, electrical, imaging, and clinical information may help inform risk stratification. Prospective studies are needed to determine whether a risk\u2011stratified approach or optimized intervention timing can modify arrhythmic risk or potentially affect long\u2011term outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11748-026-02336-1","type":"journal-article","created":{"date-parts":[[2026,6,21]],"date-time":"2026-06-21T06:07:20Z","timestamp":1782022040000},"page":"931-938","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Mitral annular disjunction and high-risk profiles: a conceptual approach to risk stratification and surgical implications"],"prefix":"10.1007","volume":"74","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5264-9659","authenticated-orcid":false,"given":"Koji","family":"Furukawa","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hirohito","family":"Ishii","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shuhei","family":"Sakaguchi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kousuke","family":"Mori","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ayaka","family":"Iwasaki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Risa","family":"Meiri","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,6,21]]},"reference":[{"key":"2336_CR1","doi-asserted-by":"publisher","first-page":"323","DOI":"10.1016\/S0022-5223(19)39144-5","volume":"86","author":"A Carpentier","year":"1983","unstructured":"Carpentier A. 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Furukawa has no conflict of interest. H. Ishii has no conflict of interest. S. Sakaguchi has no conflict of interest. K. Mori has no conflict of interest. A. Iwasaki has no conflict of interest. R. Meiri has no conflict of interest.","order":1,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"This is a narrative review, and institutional ethical approval was waived.","order":2,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Declarations"}}]}}