Mitral valve prolapse (MVP) is usually asymptomatic, but can be associated with complications such as infective endocarditis, mitral regurgitation, thromboembolism and sudden cardiac death. Myxomatous degeneration is the most common cause of MVP and it can be associated with involvement of the other valves.

     Mitral annular disjunction (MAD) is an associated abnormality where a portion of the mitral valve annulus attaches superiorly in the left atrial wall. This abnormal displacement may lead to fibrosis in the region of the disjunction and may serve as a nidus for arrhythmias. The association between MVP with MAD and its predisposition to ventricular arrhythmias (VAs) such as ventricular fibrillation (VF), ventricular tachycardia (VT), and premature ventricular contraction (PVCs) has been reported in multiple studies and case reports. While MAD is increasingly recognized, its clinical significance, especially in association with MVP, remains an area of active investigation.

     It is very well known that MVP may lead to mitral valve regurgitation which may increase over time and cause moderate to severe mitral regurgitation with the development left ventricular (LV) systolic dysfunction in later stages. 2-Dimensional speckle tracking echocardiography has been utilized for more than two decades to detect LV systolic dysfunction by LV strain imaging, which may pick up the LV aberrations priorto its presentation on routine 2-Dimensional echocardiography.

     We present here a case of 54 year Indian male presenting with MVP accompanied by significant mitral annulus disjunction (MAD) in whom a comprehensive transthoracic echocardiography (TTE) and 4Dimensional XStrain speckle tracking imaging was conducted to estimate the MAD distance and importantly, various LV strain parameters were evaluated. Perhaps this is the first case report of impact of MVP and MAD on LV deformation parameters evaluated by 4Dimensional XStrain speckle tracking echocardiography (STE).