Hidden Heart Strain Patterns Revealed in Mitral Valve Prolapse

Mitral valve prolapse is one of the most common heart valve conditions in the world, affecting roughly two to three percent of the population, yet more than a century after its first description its underlying mechanisms remain surprisingly poorly understood. Now a large retrospective study from the Deutsches Herzzentrum der Charité in Berlin has used cardiovascular magnetic resonance feature tracking to map, segment by segment, how the left ventricle deforms differently in people with prolapse compared with healthy hearts. The findings, published in Clinical Research in Cardiology, reveal a striking regional fingerprint: weakened contraction at the base of the heart’s main pumping chamber, compensated by unusually vigorous deformation at the apex, even while the heart’s global pumping measures look essentially normal.

The research team, led by Jeffrey Ji-Peng Li and Patrick Doeblin, identified 132 patients with mitral valve prolapse among all individuals who underwent cardiac magnetic resonance imaging at their institution between 2013 and 2022. These patients were compared with 50 controls without any apparent cardiac disease, drawn from five previous prospective studies. The scans were performed on 1.5-Tesla and 3-Tesla scanners using standard cine imaging, and strain analysis was carried out semiautomatically with the MEDIS QStrain 4.1 software. Because feature tracking can be applied retrospectively to existing cine images, the method allowed the researchers to extract detailed deformation data from nearly a decade of routine clinical scans.

Strain analysis quantifies how much the heart muscle shortens, thickens, or lengthens during each heartbeat, expressed as a percentage change from its resting dimension. Longitudinal strain describes the shortening of the heart muscle along its long axis, and in a healthy ventricle the values are negative, becoming more negative with stronger contraction. Feature tracking works by identifying grayscale patterns on the endocardial and epicardial borders of cine images and following them frame by frame across the cardiac cycle. This differs fundamentally from echocardiographic speckle tracking, which follows acoustic markers within the tissue, meaning that strain values from the two modalities are not directly interchangeable, although global measures correlate reasonably well.

The headline result was a clear base-to-apex gradient in longitudinal strain. After adjusting for age and sex, patients with prolapse showed less negative, meaning impaired, strain values in all basal segments of the left ventricle, with the largest deficits in the basal anterolateral segment, where the adjusted difference reached 6.0 percentage points, followed by the basal inferior and basal anterior segments. Parts of the medial wall were also affected, particularly the medial anterior and medial anterolateral segments. In contrast, the apical segments showed more negative, meaning enhanced, strain values compared with controls, with differences of up to 5.4 percentage points in the apical inferior region. The apex itself and most of the remaining medial segments were similar between the two groups.

Crucially, this regional imbalance cancelled itself out at the global level. Left ventricular global longitudinal strain, global circumferential strain, and right ventricular free wall longitudinal strain were all statistically comparable between patients and controls. The only global parameter that stood apart was left atrial reservoir strain, which showed a trend toward reduction in the prolapse group, a notable finding because the researchers had deliberately excluded anyone with moderate or worse valve leakage. This hints at what the authors describe as a possible primary atriopathy, in which the abnormal motion of the prolapsing leaflets stretches the atrial walls and drives remodeling, independent of any regurgitant volume.

The mechanical explanation for the basal strain deficits likely lies in the peculiar anatomy of prolapse. In the Berlin cohort, 68 percent of patients showed systolic curling, an abnormal motion of the posterior mitral ring relative to the adjacent myocardium, and many had mitral annular disjunction, a separation of the valve annulus from the underlying heart muscle visible in both systole and diastole. These structural abnormalities alter how contractile forces are transmitted through the basal myocardium, and the reduced strain values there may reflect a combination of genuine contractile impairment and measurement effects arising from the distorted mechanics. Disentangling the two is precisely what the study set out to quantify, so that clinicians interpreting regional strain in prolapse patients can better judge when an abnormality signals true myocardial disease rather than a mechanical artifact.

Supporting the idea that at least part of the basal impairment is real, 19 of the 114 patients who received contrast-enhanced imaging showed signs of local myocardial fibrosis, concentrated in the basal and medial inferior and inferolateral walls, exactly the regions with the worst strain values. Fibrosis near the mitral annulus is a well-recognized feature of prolapse and is clinically important because of its association with ventricular arrhythmias and sudden cardiac death. The proportion observed here, roughly 17 percent, sits close to the 25 percent reported in earlier studies. Abnormal mechanical stress from the prolapsing leaflets may trigger remodeling processes that promote fibrosis, and fibrotic tissue in turn contracts poorly, creating a plausible feedback loop between valve mechanics and myocardial injury.

One of the most novel observations was a strain ratio comparing the basal anterolateral segment with the apical lateral segment. This ratio was significantly lower in prolapse patients than in controls, indicating a predominant apical deformation of the lateral wall, a pattern not previously described. Intriguingly, patients with mitral annular disjunction showed a slightly higher ratio than those without, suggesting that in disjunction the compensatory boost in apical contraction is blunted. The authors speculate that this loss of apical compensation could represent a mechanistic link between annular disjunction and the elevated arrhythmic risk reported in prior studies, although they caution that the fibrosis subgroup was small and not all patients underwent contrast imaging, so the interpretation remains provisional.

To test whether the pattern was an artifact of magnetic resonance feature tracking, the team repeated the analysis in a small subgroup of 19 patients and 9 controls who also had transthoracic echocardiograms suitable for speckle tracking. Despite the limited sample, the echocardiographic data reproduced the same regional signature, with worse strain at the base and better strain at the apex in prolapse patients. This cross-modality agreement strengthens the case that the pattern reflects a genuine mechanical phenomenon of the prolapsing heart rather than a quirk of one imaging technology, though the authors note that the choice of analysis software can itself influence strain results and may partly explain why earlier studies reached conflicting conclusions.

The study has limitations worth keeping in view. It was retrospective, and most patients were referred for magnetic resonance for reasons other than the valve condition itself, such as breathlessness or suspected cardiomyopathy, so the cohort may not perfectly represent the asymptomatic majority of prolapse cases. Images were acquired over ten years on scanners of two different field strengths, although prior work suggests this has minimal impact on strain measurements. The prolapse itself was generally mild, with an average displacement of the leaflets of only 4.4 millimeters, leaving open the question of whether more severe prolapse would push the strain abnormalities further toward the mid-ventricle and apex. Even so, as the largest cardiac magnetic resonance study of regional strain in mitral valve prolapse to date, the work provides a detailed reference map of how the prolapsing heart deforms, and it lays the groundwork for future studies testing whether these strain signatures can improve risk stratification for the arrhythmias and sudden cardiac death that remain the most feared complications of this common condition.

Subject of Research: Regional left ventricular strain patterns measured by cardiovascular magnetic resonance feature tracking in patients with mitral valve prolapse

Article Title: Regional strain patterns in patients with mitral valve prolapse

Article References: Li, J. J.-P., Ching, S., Aigner, A., Edelmann, F., Werhahn, S. M., Beyer, R., Schulz-Menger, J., Erley, J., Estepa, M., Meuwly, C., Eggers, A.-S., Stehning, C., Hashemi, D., Solowjowa, N., Klein, C., Hilgendorf, I., Kelle, S., & Doeblin, P. (2026). Regional strain patterns in patients with mitral valve prolapse. Clinical Research in Cardiology. https://doi.org/10.1007/s00392-026-03033-y

Image Credits: AI Generated

DOI: 10.1007/s00392-026-03033-y

Keywords: mitral valve prolapse, cardiac magnetic resonance, feature tracking, longitudinal strain, left ventricle, mitral annular disjunction, myocardial fibrosis, left atrial strain, ventricular arrhythmia, cardiology, strain analysis, valvular disease