True vs pseudo mitral annular dysjunction on echocardiography

True mitral annular disjunction (MAD) is a genuine structural abnormality in which there is a real separation between the hinge point of the posterior mitral leaflet and the left ventricular myocardium. On echocardiography, especially in parasternal long-axis view during systole, the mitral annulus is seen displaced atrially with a clear gap between the annulus and the ventricular wall. This separation persists consistently, is best appreciated in systole, and is often associated with mitral valve prolapse, excessive annular motion, and sometimes ventricular arrhythmias.

Pseudo mitral annular disjunction is an apparent or false impression of annular separation caused by imaging artifacts or altered cardiac geometry rather than a true anatomic defect. It may be seen due to oblique imaging planes, heavy mitral annular calcification, leaflet billowing, translational motion of the heart, or marked left atrial enlargement. In pseudo MAD, the apparent gap disappears with correct probe alignment, different views, or frame-by-frame analysis, and there is no true detachment of the annulus from the ventricular myocardium.

Practical echo tip: true MAD is reproducible across views, maximal in systole, and shows a real myocardial-annular separation, whereas pseudo MAD is view-dependent, inconsistent, and resolves with optimized imaging.

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