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Original Investigation
July 7, 2021

Association of Mitral Annular Disjunction With Cardiovascular Outcomes Among Patients With Marfan Syndrome

Author Affiliations
  • 1Centre for Medical Genetics, Ghent University Hospital, Ghent, Belgium
  • 2Department of Cardiology, Ghent University Hospital, Ghent, Belgium
  • 3Department of Paediatrics, Division of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
JAMA Cardiol. Published online July 7, 2021. doi:10.1001/jamacardio.2021.2312
Key Points

Question  What is the association of mitral annular disjunction (MAD) with cardiovascular outcomes among patients with Marfan syndrome (MFS)?

Findings  In this cohort study of 142 patients with MFS, MAD was found in 34% and was associated with a higher need for mitral valve intervention, occurrence of arrhythmic events (defined as sustained ventricular tachycardia and sudden cardiac death), and, among patients with extensive MAD, more aortic events. In addition, ventricular arrhythmia, but not atrial arrhythmia, was more often observed among patients with MAD.

Meaning  This study suggests that reporting on the presence and extent of MAD should be considered in the routine cardiac evaluation of patients with MFS as a potential marker for adverse outcomes.


Importance  Mitral annular disjunction (MAD) has received particular interest in patients with mitral valve prolapse, ventricular tachycardia, and sudden cardiac death. The clinical significance of MAD for patients with Marfan syndrome (MFS) remains largely unexplored.

Objective  To define the prevalence of MAD and examine its association with cardiovascular outcomes and arrhythmia among patients with MFS.

Design, Setting, and Participants  This retrospective, single-center cohort study included 142 patients with a diagnosis of MFS based on the revised Ghent criteria and a confirmed (likely) pathogenic variant in the FBN1 gene who underwent regular follow-up between January 1, 2004, and December 31, 2019.

Main Outcomes and Measures  The presence of MAD was assessed by echocardiography, and the extent of MAD was categorized in tertiles. Patients also underwent resting electrocardiography and 24-hour Holter monitoring. Outcomes included aortic events (aortic dissection or prophylactic aortic surgery), arrhythmic events (defined as sustained ventricular tachycardia or sudden cardiac death), and mitral valve surgery.

Results  A total of 142 patients (72 female patients [51%]; median age at first examination, 25 years [range, 2-64 years]) were evaluated. Forty-eight patients (34%) had MAD. Patients with MAD had larger aortic root z scores than patients without MAD (4.1 [interquartile range, 2.8-5.7] vs 3.0 [interquartile range, 1.8-4.0]; P < .001) and more often had mitral valve prolapse (34 of 48 [71%] vs 14 of 94 [15%]; P < .001), ventricular ectopy (14 of 33 [42%] vs 15 of 70 [21%]; P = .03), and nonsustained ventricular tachycardia (13 of 33 [39%] vs 12 of 70 [17%]; P = .01). During follow-up, aortic events occurred at similar rates among patients with vs without MAD (15 of 43 [35%] vs 21 of 84 [25%]; P = .24), but patients in the upper MAD tertile (>10 mm) showed a higher occurrence of aortic events compared with patients with MAD of 10 mm or smaller (9 of 15 [60%] vs 6 of 28 [21%]; P = .01). Patients with arrhythmic events (n = 5) and patients requiring mitral valve surgery (n = 7) were observed exclusively in the group displaying MAD.

Conclusions and Relevance  This study suggests that MAD among patients with MFS is associated with the occurrence of arrhythmic events, a higher need for mitral valve intervention, and, among patients with extensive MAD, more aortic events. Cardiac imaging for patients with MFS should consider the assessment of MAD as a potential marker for adverse outcomes.

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