Non-Myxomatous Flail Mitral Valve: Clinical and Echocardiographic Characteristics and Long-Term Clinical Outcome Salim Adawi 1 , Doron Aronson 2 , David A. Halon 1 , Sigal Aviram 1 , Basil S. Lewis 1 , Avinoam Shiran 1 1 Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 2 Rambam Medical Center and the Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel Ruptured chordae tendineae leading to flail mitral valve leaflet usually results in severe mitral regurgita- tion (MR) that leads to left ventricular dysfunction, heart failure and, if not corrected surgically in time, the patient’s death (1-3). In developed countries, flail leaflet is the leading cause of severe MR (1,2). Although ruptured chordae has been reported to be associated primarily with myxomatous mitral valve disease, it may also be caused by infective endocarditis or trauma (4-7). In other cases it may be either ‘prim- ary’ or ‘idiopathic’ as a result of a degenerative process. At present, few data exist regarding the preva- lence, clinical and echocardiographic features and out- come of this group of patients (6-8). Furthermore, as the mean age of the patient population continues to rise, non-myxomatous ruptured chordae and flail leaflet may become more prevalent. Both, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) can be used for the reliable detection of flail leaflet and ruptured chordae, and also to delineate the anatomy of the mitral valve and degree of mitral regurgitation (9-14). The study aim was to assess the prevalence of myxo- matous and non-myxomatous flail mitral valve in patients referred for echocardiography, and to com- pare the clinical and echocardiographic characteristics of these conditions. Presented at the American College of Cardiology 55th Annual Scientific Meeting, March 2006, Atlanta, and at the Euroecho10 meet- ing, December 2006, Prague Address for correspondence: Avinoam Shiran MD, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal Street, Haifa 34362, Israel e-mail: shiranad@012.net.il © Copyright by ICR Publishers 2007 Background and aim of the study: Chordal rupture leading to flail mitral valve and mitral regurgitation (MR) is considered to be caused primarily by myxo- matous mitral valve disease. The study aim was to determine the prevalence and clinical and echocar- diographic characteristics of non-myxomatous versus myxomatous flail mitral valve. Methods: A total of 96 patients with flail mitral valve was identified from an echocardiography database and classified as either myxomatous (n = 36; 37%) or non-myxomatous (n = 60; 63%), based on echocardio- graphic mitral valve anatomy (systolic leaflet buck- ling). In 10 other patients the etiology was indeterminate. The clinical and echocardiographic characteristics and outcome at five years were com- pared between groups. Results: Patients with non-myxomatous mitral valve were older than those with myxomatous mitral valve (mean age 76 ± 9 versus 61 ± 12 years; p <0.0001), and were more likely to have aortic sclerosis, mitral annulus and papillary muscle calcification (odds ratio 3.6, 95% CI 1.2-10.8, p = 0.02) and to have short duration of symptoms (≤1 month, p <0.02). There was no inter-group difference in MR severity, but non- myxomatous patients had higher systolic pulmonary artery pressure (52 ± 16 versus 42 ± 13 mmHg, p = 0.008). During the five-year follow up period, non- myxomatous patients had a poorer crude survival and survival free from rehospitalization for heart failure (p = 0.02), and were less likely to have mitral valve surgery (p = 0.015). However, these differences were abolished when data were adjusted for age. Conclusion: Among patients with flail mitral valve referred for echocardiography, more than half were non-myxomatous in origin, most likely due to wear and tear. Non-myxomatous flail mitral valve was associated with older age, degenerative calcific valvular changes, and more recent onset of symp- toms. Age-adjusted survival free of heart failure was similar in both non-myxomatous and myxomatous patients. The Journal of Heart Valve Disease 2007;16:336-343