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Sex Differences in Morphology and Outcomes of Mitral Valve Prolapse

Jean-François Avierinos, MD; Jocelyn Inamo, MD; Francesco Grigioni, MD; Bernard Gersh, MD; Clarence Shub, MD; and Maurice Enriquez-Sarano, MD
[+] Article, Author, and Disclosure Information

From Hôpital La Timone, Marseille, France; Ospedale de l'Università di Bologna, Bologna, Italy; and the Mayo Clinic, Rochester, Minnesota.

Potential Financial Conflicts of Interest:Consultancies: B. Gersh (AstraZeneca, Boston Scientific, Novartis, Abbott Laboratories), M. Enriquez-Sarano (Edwards Life Science). Honoraria: F. Grigioni (Edwards Life Science), M. Enriquez-Sarano (Edwards Life Science). Stock ownership or options (other than mutual funds): B. Gersh (CV Therapeutics). Grants received: M. Enriquez-Sarano (Edwards Life Science, AstraZeneca, Pfizer).

Reproducible Research Statement:Study protocol, statistical code, and data set: Not available.

Requests for Single Reprints: Maurice Enriquez-Sarano, MD, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905; e-mail, sarano.maurice@mayo.edu.

Current Author Addresses: Dr. Avierinos: Service de Cardiologie, Hôpital La Timone, Marseille, France.

Dr. Inamo: Service de Cardiologie, Centre Hospitalo-Universitaire Fort-de-France, Fort-de-France, France.

Dr. Grigioni: Clinica de Cardiologia, Ospedale de l'Università di Bologna, Bologna, Italy.

Drs. Gersh, Shub, and Enriquez-Sarano: Mayo Clinic, 200 First Street SW, Rochester, MN 55905.

Author Contributions: Conception and design: J.F. Avierinos, M. Enriquez-Sarano.

Analysis and interpretation of the data: J.F. Avierinos, F. Grigioni, C. Shub, M. Enriquez-Sarano.

Drafting of the article: J.F. Avierinos, F. Grigioni, C. Shub, M. Enriquez-Sarano.

Critical revision of the article for important intellectual content: J.F. Avierinos, J. Inamo, F. Grigioni, C. Shub, M. Enriquez-Sarano.

Final approval of the article: J. Inamo, C. Shub, M Enriquez-Sarano.

Provision of study materials or patients: M. Enriquez-Sarano.

Statistical expertise: J.F. Avierinos, M. Enriquez-Sarano.

Obtaining of funding: M. Enriquez-Sarano.

Administrative, technical, or logical support: B. Gersh.

Collection and assembly of data: J.F. Avierinos, J. Inamo, M. Enriquez-Sarano.

Ann Intern Med. 2008;149(11):787-794. doi:10.7326/0003-4819-149-11-200812020-00003
Text Size: A A A

Background: Mitral valve prolapse is more common in women than in men, but men more often have surgery for severe regurgitation.

Objective: To compare morphology and outcomes of mitral valve prolapse in men and women.

Design: Retrospective cohort study.

Setting: The Mayo Clinic, Rochester, Minnesota.

Patients: 4461 women and 3768 men who received a diagnosis of mitral valve prolapse by echocardiography from 1989 to 1998 (896 Olmsted County residents and 7333 referred patients).

Measurements: Mitral prolapse characteristics (localization, leaflet thickening or flail, regurgitation), ventricular and atrial characteristics, cardiac surgery, and mortality.

Results: Compared with men, women had less posterior prolapse (22% vs. 31%), less flail (2% vs. 8%), more leaflet thickening (32% vs. 28%), and less frequent severe regurgitation (10% vs. 23%) (P < 0.001 for all comparisons). Regardless of the severity of regurgitation, left ventricular and atrial diameters were smaller in women than in men but were larger in women after normalization to body surface area. Among patients with severe regurgitation, women were less likely than men to undergo cardiac valve surgery (52% vs. 60%; adjusted risk ratio, 0.79 [95% CI, 0.74 to 0.84]). At 15 years, women with no or mild mitral regurgitation had better odds of survival than men (87% vs. 77%; adjusted risk ratio, 0.82 [CI, 0.76 to 0.89]), but those with severe regurgitation had worse survival than men (60% vs. 68%; adjusted risk ratio, 1.13 [CI, 1.01 to 1.26]). The survival rate 10 years after surgery was similar in women and men (77% vs. 79%; P = 0.14). Observations in Olmsted County patients and referred patients were similar.

Limitation: Diagnoses were based on echocardiography, and clinical data at initial diagnosis, reason for index echocardiography, and cause of all deaths were lacking.

Conclusion: Morphology and severity of mitral valve prolapse differ according to sex. Among patients with severe regurgitation, women have higher mortality and lower surgery rates than men.


Grahic Jump Location
Sex-specific differences in survival after diagnosis of mitral valve prolapse.

P values are for the log-rank direct comparison of survival between women and men. MR = mitral regurgitation; RR = risk ratio.

Grahic Jump Location




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Submit a Comment/Letter
Mitral valve prolapse in Marfan syndrome
Posted on December 2, 2008
Weekitt Kittisupamongkol
Hua Chiew Hospital, Bangkok 10100, Thailand
Conflict of Interest: None Declared

I read with interest the article by Avierinos and colleagues(1). The authors are not aware of Marfan syndrome which is a common genetic disorder in the United States. The prevalence of mitral valve prolapse in patients with Marfan syndrome is more than 90%(2). Life-threatening complications of such syndrome are aortic root dilatation and aortic dissection(3). However, echocardiographic characteristics in the study do not mention the aorta. This would lead to include the abnormal aorta from Marfan syndrome in the patients presenting with mitral valve prolapse and overestimate mortality rates of mitral valve prolapse accordingly.


1. Avierinos J, Inamo J, Grigioni F, Gersh B, Shub C, Enriquez-Sarano M. Sex differences in morphology and outcomes of mitral valve prolapse. Ann Intern Med 2008; 149: 787-794

2. Hayek E, Gring CN, Griffin BP. Mitral valve prolapse. Lancet 2005; 365: 507-18

3. Judge DP, Dietz HC. Marfan's syndrome. Lancet 2005; 366: 1965-76

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Differences in Mitral Valve Prolapse between Men and Women

The summary below is from the full report titled “Sex Differences in Morphology and Outcomes of Mitral Valve Prolapse.” It is in the 2 December 2008 issue of Annals of Internal Medicine (volume 149, pages 787-794). The report was written by J.F. Avierinos, J. Inamo, F. Grigioni, B. Gersh, C. Shub, and M. Enriquez-Sarano.


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