Mitral annulus disjunction is associated with adverse outcome in Marfan and Loeys-Dietz syndromes

Eur Heart J Cardiovasc Imaging. 2021 Aug 14;22(9):1035-1044. doi: 10.1093/ehjci/jeaa324.


Aims: We aimed to assess the prevalence of mitral annulus disjunction (MAD) and to explore the association with aortic disease and mitral valve surgery in patients with Marfan syndrome (MFS) and Loeys-Dietz syndrome (LDS).

Methods and results: We included consecutive MFS patients fulfilling Revised Ghent Criteria and LDS patients fulfilling Loeys-Dietz Revised Nosology. MAD was identified by echocardiography and was quantified as the longitudinal distance from the ventricular myocardium to the hinge point of the posterior mitral leaflet. Aortic events were defined as aortic dissection or prophylactic aortic surgery. We recorded the need of mitral valve surgery including mitral valve repair or replacement. We included 168 patients (103 with MFS and 65 with LDS). The prevalence of MAD was 41%. MAD was present in all age groups. Aortic events occurred in 112 (67%) patients (27 with dissections and 85 with prophylactic surgical interventions). Patients with MAD were younger at aortic event than those without MAD (log rank = 0.02) Patients with aortic events had greater MAD distance in posterolateral wall [8 (7-10) mm vs. 7 (6-8) mm, P = 0.04]. Mitral events occurred more frequently in patients with MAD (P < 0.001).

Conclusion: MAD was highly prevalent in patients with MFS and LDS. MAD was a marker of severe disease including aortic events at younger age and need of mitral valve surgery. Screening patients with MFS an LDS for MAD may provide prognostic information and may be relevant in planning surgical intervention. Detection of MAD in patients with MFS and LDS may infer closer clinical follow-up from younger age.

Keywords: Loeys–Dietz; Marfan; aortic syndrome; mitral annulus disjunction; mitral valve disease; mitral valve prolapse.

MeSH terms

  • Aorta
  • Cardiac Surgical Procedures* / adverse effects
  • Humans
  • Loeys-Dietz Syndrome* / diagnostic imaging
  • Loeys-Dietz Syndrome* / epidemiology
  • Loeys-Dietz Syndrome* / surgery
  • Marfan Syndrome* / complications
  • Marfan Syndrome* / diagnostic imaging
  • Marfan Syndrome* / epidemiology
  • Mitral Valve / diagnostic imaging
  • Mitral Valve / surgery