Sex Differences in Mitral Annular Disjunction in Patients Undergoing Cardiac Magnetic Resonance Imaging

Thursday, February 5, 2026

3:45 PM - 3:52 PM

Location: Galapagos / Aruba / Ilhabela (2nd Lower Level)

Presenting Author(s)

Natalie Swope, BSc

Research Coordinator
The Christ Hospital Health Network
North Bend, Ohio, United States

Primary Author(s)

Natalie Swope, BSc

Research Coordinator
The Christ Hospital Health Network
North Bend, Ohio, United States

Co-Author(s)

Cassady Palmer, BSc

Research Associate
The Christ Hospital Health Network
Cincinnati, Ohio, United States
CS

Christian Schmidt, PhD

Biomedical Statistician
The Christ Hospital Health Network, United States
WM

Wojciech M Mazur, MD

Director of Advanced Cardiac Imaging
The Christ Hospital Health Network
Cincinnati, Ohio, United States

Background: Mitral Annular Disjunction (MAD) is associated with mitral valve prolapse (MVP) and is characterized by separation between the LV free wall, left atrium, and the mitral valve (MV) leaflet attachments during systole. This often results in myocardial scarring culminating in sudden fatal arrhythmia and disproportionately affects women.^1-3 Our study aims to investigate sex differences in parametric mapping features by cardiac magnetic resonance imagining (CMR) in patients identified with MAD.

Methods: This retrospective study was conducted on 136 patients diagnosed with MVP who underwent consecutive CMRs at a single care center between 2019 and 2022. Of these, 50 were identified with MAD. The severity of MAD was evaluated by SSFP sequenced imaging on 3 chamber axis plane measuring from the mitral disjunction distance from the LV wall to left atrial wall. Parametric polar maps were generated for native T1, T2, and EVC values. When a distinctive semilunar pattern of focally elevated ECV was present remaining segments were ratio to evaluated regions.

Results: Of the 50 patients with MAD (age 55 ± 15 years; 62% female), the MAD ECV pattern was identified in 35 (70%). The MAD distance measured by CMR was 7 mm (interquartile range [IQR]: 5 to 9mm) in females and 9 mm (IQR: 5 to 13mm) in males. Female patients had greater native T1 values of segments 9-11 when compared to T1 values at segments 1-8 (1087 ± 57 vs 1052 ± 42; p < 0.001).

Conclusion: Our study we identified a predominance of MAD among female patients and can be identified by a CMR parametric pattern. Due to a strong association of MAD and fatal cardiac arrhythmic events, the use of standard utilization of ECV mapping and T1 values may be useful tools for providing patients earlier and accurate diagnosis of MAD⁴.

Baseline Patient Characteristics and Tissue Characteristics

Variable	No MAD Pattern N=14	ECV MAD pattern N=35	p-value
Age, median (IQR)	61 (47, 68)	59 (46, 66)	0.682
Male, n (%)	6 (43)	12 (34)	0.574
BMI, mean ± SD	23.7 ± 4.3	24.5 ± 4.4	0.600
BSA, mean ± SD	1.85 ± 0.30	1.83 ± 0.22	0.759
HTN, n (%)	8 (57)	10 (29)	0.061
HCM, n (%)	1 (7)	0 (0)	0.286
Pre-DM, n (%)	4 (29)	3 (9)	0.091
DM, n (%)	1 (7)	1 (3)	0.494
Suspected OSA, n (%)	0 (0)	3 (9)	0.548
OSA, n (%)	2 (14)	6 (17)	1.000
Obesity, n (%)	1 (7)	4 (11)	1.000

Holter Monitor, n (%)	9 (64)	19 (54)	0.523
PVC burden, median (IQR)	1.7 (0.1, 6.0)	2.3 (0.7, 6.8)	0.535
ICD/PPM, n (%)	2 (14)	4 (11)	1.000
QRS duration, median (IQR)	93 (91, 100)	99 (89, 114)	0.267
MAD Distance, median (IQR)	5.5 (4, 9)	8 (6, 11)	0.006
T1 Slice 9, median (IQR)	1056 (1012, 1081)	1059 (1020, 1116)	0.680
T1 Slice 10, mean ± SD	1051 ± 32	1094 ± 61	0.024
T1 Slice 11, mean ± SD	1053 ± 52	1070 ± 46	0.292
T1 Slices 9-11	1050 ± 33	1080 ± 60	0.113
T1 Other Slices	1049 ± 25	1047 ± 47	0.905
Comparing 9-11 to other slices	P=0.850	P< 0.001
T2 Slice 9, mean ± SD	410 ± 60	413 ± 44	0.870
T2 Slice 10, mean ± SD	406 ± 56	404 ± 47	0.909
T2 Slice 11, median (IQR)	418 (391, 436)	413 (382, 433)	0.905
T2 Slices 9-11	406 ± 54	413 ± 46	0.646
T2 Other Slices	412 ± 53	419 ± 39	0.650
Comparing 9-11 to other slices	P=0.176	P=0.001

Sex differences in MAD patients

Variable	Female N=31	Male N=19	p-value
Age, median (IQR)	58 (46, 65)	61 (41, 70)	0.364
BMI, mean ± SD	23.3 ± 4.5	25.3 ± 4.3	0.123
BSA, mean ± SD	1.70 ± 0.17	2.05 ± 0.18	< 0.001
HTN, n (%)	7 (23)	11 (58)	0.012
HCM, n (%)	0 (0)	1 (5)	0.380
Pre-DM, n (%)	4 (13)	3 (16)	1.000
DM, n (%)	1 (3)	1 (5)	1.000
Suspected OSA, n (%)	2 (6)	1 (5)	1.000
OSA, n (%)	4 (13)	4 (21)	0.459
Obesity, n (%)	2 (6)	3 (16)	0.355

ECV Mad Pattern	23 (74)	12 (67)	0.574
MAD Distance, median (IQR)	7 (5, 9)	9 (5, 13)	0.245
Holter Monitor, n (%)	18 (58)	10 (53)	0.707
PVC burden, median (IQR)	2.3 (0.7, 13.0)	1.7 (0.5, 4.0)	0.387
ICD/PPM, n (%)	4 (13)	3 (16)	1.000
QRS duration, median (IQR)	99 (89, 106)	95 (90, 106)	0.871
T1 Slice 9, median (IQR)	1067 (1032, 1120)	1029 (969, 1069)	0.018
T1 Slice 10, mean ± SD	1096 ± 63	1061 ± 41	0.042
T1 Slice 11, mean ± SD	1072 ± 41	1054 ± 55	0.227
T1 Slices 9-11	1087 ± 57	1049 ± 47	0.019
T1 Other Slices	1052 ± 42	1039 ± 43	0.322
Comparing 9-11 to other slices	P< 0.001	0.134
T2 Slice 9, mean ± SD	415 ± 48	407 ± 50	0.619
T2 Slice 10, mean ± SD	403 ± 52	405 ± 46	0.883
T2 Slice 11, median (IQR)	423 (392, 435)	414 (378, 437)	0.778
T2 Slices 9-11	414 ± 49	407 ± 45	0.593
T2 Other Slices	419 ± 41	415 ± 45	0.737
Comparing 9-11 to other slices	P=0.032	P=0.001

Violin plots demonstrating sex differences in Native T1 values in ratio in AHA segments 9-11
Violin plots demonstrating sex differences in Native T1 values
Violin plots demonstrating sex differences in MAD pattern vs no MAD pattern by tissue characterization