Negative impact of high-performance flights on aviators with mitral valve prolapse

Published:November 23, 2022DOI:


      • High-performance flight has no deleterious effects on hearts of healthy aviators.
      • High-performance flight may result in worsening regurgitation in aviators with mitral valve prolapse (MVP).
      • High-performance aviators with MVP required more mitral surgery.



      While it appears not to affect healthy aviators' hearts, there are scarce data regarding the impact of high-performance flights on aviators with mitral valve prolapse (MVP).


      A retrospective, comparative cohort study of military aviators with MVP. Subjects were categorized to either high-performance (jet fighter) or low-performance (transport and helicopter) aviators.
      The primary outcomes were the rates of mitral interventions and of adverse cardiovascular events since being an aircrew candidate and up to the end of flying career. Additional outcomes were echocardiographic measurements and the cumulative proportion of mitral valve interventions over time.


      Of 33 male aviators with MVP, 18 were high-performance aviators. On average, follow-up started at age 18.5 years and lasted 27.8 ± 10.1 years. Baseline characteristics were similar between the study groups. Aviators of high-performance aircraft had increased rates of mitral valve surgery (33 % vs. 0, p = 0.021), MVP-related complications (39 % vs. 6.7 %, p = 0.046), and a higher incidence of mitral valve repair over time (p = 0.02). High-performance flight was associated with increased intraventricular septum thickness (IVS, 9.7 mm vs 8.9 mm, p = 0.015) and IVS index (p = 0.026) at the last echocardiographic assessment. High-performance aviators tended to develop worsening severity of mitral regurgitation.


      High-performance flight may be associated with an increased risk for valvular deterioration and need for mitral surgery in aviators with MVP.

      Graphical abstract


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Avierinos J.F.
        • Gersh B.J.
        • Melton L.J.
        • Bailey K.R.
        • Shub C.
        • Nishimura R.A.
        • et al.
        Natural history of asymptomatic mitral valve prolapse in the community.
        Circulation. 2002; 106: 1355-1361
        • Freed L.A.
        • Benjamin E.J.
        • Levy D.
        • Larson M.G.
        • Evans J.C.
        • Fuller D.L.
        • et al.
        Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham heart study.
        J Am Coll Cardiol. 2002; 40: 1298-1304
        • Delling F.M.
        • Vasan R.S.
        Epidemiology and pathophysiology of mitral valve prolapse: new insights into disease progression, genetics, and molecular basis.
        Circulation. 2014; 129: 2158-2170
        • Antoine C.
        • Benfari G.
        • Michelena H.I.
        • Maalouf J.F.
        • Nkomo V.T.
        • Thapa P.
        • et al.
        Clinical outcome of degenerative mitral regurgitation: critical importance of echocardiographic quantitative assessment in routine practice.
        Circulation. 2018; 138: 1317-1326
        • Ma J.I.
        • Igata S.
        • Strachan M.
        • Nishimura M.
        • Wong D.J.
        • Raisinghani A.
        • et al.
        Predictive factors for progression of mitral regurgitation in asymptomatic patients with mitral valve prolapse.
        Am J Cardiol. 2019; 123: 1309-1313
        • Nicol E.D.
        • Rienks R.
        • Gray G.
        • Guettler N.J.
        • Manen O.
        • Syburra T.
        • et al.
        An introduction to aviation cardiology.
        Heart. 2019; 105: s3-s8
        • Freed L.A.
        • Levy D.
        • Levine R.A.
        • Larson M.G.
        • Evans J.C.
        • Fuller D.L.
        • et al.
        Prevalence and clinical outcome of mitral valve prolapse.
        N Engl J Med. 1999; 341: 1-7
        • Bonow R.O.
        • Carabello B.A.
        • Chatterjee K.
        • de Leon Jr., A.C.
        • Faxon D.P.
        • Freed M.D.
        2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
        Circulation. 2008; 118: e523-e661
        • Lang R.A.
        • Bierig M.
        • Devereux R.B.
        • Flachskampf F.A.
        • Foster E.
        • Pellikka P.A.
        • et al.
        Recommendations for chamber quantification: a report from the American Society of Echocardiography's guidelines and standards committee and the chamber quantification writing group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology.
        J Am Soc Echocardiogr. 2005; 18: 1440-1463
        • Zoghbi W.A.
        • Enriquez-Sarano M.
        • Foster E.
        • Grayburn P.A.
        • Kraft C.D.
        • Levine R.A.
        • et al.
        Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography.
        J Am Soc Echocardiogr. 2003; 16: 777-802
        • Gardin J.M.
        • Adams D.B.
        • Douglas P.S.
        • Feigenbaum H.
        • Forst D.H.
        • Fraser A.G.
        • et al.
        Recommendations for a standardized report for adult transthoracic echocardiography: a report from the American Society of Echocardiography's nomenclature and standards committee and task force for a standardized echocardiography report.
        J Am Soc Echocardiogr. 2002; 15: 275-290
        • Assa A.
        • Prokupetz A.
        • Wand O.
        • Harpaz D.
        • Grossman A.
        Echocardiographic evaluation and follow-up of cardiac and aortic indexes in aviators exposed to acceleration forces.
        J Am Soc Echocardiogr. 2011; 24: 1163-1167
        • AGARD Aerospace Medical Panel Working Group 18
        Echocardiographic findings in NATO pilots: do acceleration (+Gz) stresses damage the heart? AGARD, Neuilly-sur-Seine, France.
        Aviat Space Environ Med. 1997; 68: 596-600
        • Harpaz D.
        • Kriwisky M.
        • Fineman R.
        • Haim A.
        • Lewis B.S.
        • Shamiss A.
        Effect of high gravity on cardiac dimensions in trained air crew.
        Am J Cardiol. 1996; 77: 1258-1260
        • Albery W.B.
        • Ten Eyck R.P.
        • Wolfe M.
        Female exposure to high G: echocardiographic evaluation for chronic changes in cardiac function.
        Aviat Space Environ Med. 1998; 69: 857-861
        • Carter D.
        • Prokupetz A.
        • Harpaz D.
        • Barenboim E.
        Effects of repeated exposure to acceleration forces (+Gz) and anti-G manoeuvres on cardiac dimensions and performance.
        Exp Clin Cardiol. 2010; 15: e10-e12
        • Öztürk C.
        • Savaş İlbasmiş M.
        • Akin A.
        Cardiac responses to long duration and high magnitude +Gz exposure in pilots: an observational study.
        Anadolu Kardiyol Derg. 2012; 12: 668-674
        • Martin D.S.
        • D'Aunno D.S.
        • Wood M.L.
        • South D.A.
        Repetitive high G exposure is associated with increased occurrence of cardiac valvular regurgitation.
        Aviat Space Environ Med. 1999; 70: 1197-1200
        • Suzuki K.
        • Murata M.
        • Yasuda R.
        • Tsuruta H.
        • Tomotsugu M.
        • Takayuki A.
        • et al.
        Effect of lesional differences in prolapsed leaflets on clinical outcomes in patients with mitral valve prolapse.
        Am J Cardiovasc Dis. 2012; 2: 152-159
        • Roberts W.C.
        • Vowels T.J.
        • Ko J.M.
        • Hebeler Jr., R.F.
        Gross and histological features of excised portions of posterior mitral leaflet in patients having operative repair of mitral valve prolapse and comments on the concept of missing (=ruptured) chordae tendineae.
        J Am Coll Cardiol. 2014; 29: 1667-1674
        • Kruithof B.P.T.
        • Paardekooper L.
        • Hiemstra Y.L.
        • Goumans M.J.
        • Palmen M.
        • Delagado V.
        • et al.
        Stress-induced remodelling of the mitral valve: a model for leaflet thickening and superimposed tissue formation in mitral valve disease.
        Cardiovasc Res. 2020; 116: 931-943
        • Stoddard M.F.
        • Prince C.R.
        • Dillon S.
        • Longaker R.A.
        • Morris G.T.
        • Liddell N.E.
        Exercise-induced mitral regurgitation is a predictor of morbid events in subjects with mitral valve prolapse.
        J Am Coll Cardiol. 1995; 25: 693-699
        • Magne J.
        • Lancellotti P.
        • Piérard L.A.
        Exercise-induced changes in degenerative mitral regurgitation.
        J Am Coll Cardiol. 2010; 56: 300-309
        • Laughlin M.H.
        The effects of +Gz on the coronary circulation: a review.
        Aviat Space Environ Med. 1986; 57: 5-16
        • MacDougall J.D.
        • Tuxen D.
        • Sale D.G.
        • Moroz J.R.
        • Sutton J.R.
        Arterial blood response to heavy resistance exercise.
        J Appl Physiol. 1985; 58: 785-790
        • Otani K.
        • Takeuchi M.
        • Kaku K.
        • Haruki N.
        • Yoshitani H.
        • Masataka E.
        • et al.
        Evidence of a vicious cycle in mitral regurgitation with prolapse: secondary tethering attributed to primary prolapse demonstrated by three-dimensional echocardiography exacerbates regurgitation.
        Circulation. 2012; 126: s214-s221
        • Gabbay U.
        • Yosefy C.
        The underlying cause of chordae tendinae rupture: a systematic review.
        Int J Cardiol. 2010; 143: 113-118
        • Brizzio M.E.
        • Zapolanski A.
        Acute mitral regurgitation requiring urgent surgery because of chordae ruptures after extreme physical exercise: a case report.
        Heart Surg Forum. 2008; 11: E255-E256
        • Grinberg A.R.
        • Finkielman J.D.
        • Piňeiro D.
        • Festa H.
        • Cazenave C.
        Rupture of mitral chorda tendinea following blunt chest trauma.
        Clin Cardiol. 1998; 21: 300-301
        • Pasquier M.
        • Sierro C.
        • Yersin B.
        • Delay D.
        • Carron P.N.
        Traumatic mitral valve injury after blunt chest trauma: a case report and review of the literature.
        J Trauma. 2010; 68: 243-246
        • Moore M.N.
        • Climie R.E.
        • Otahal P.
        • Sharman J.E.
        • Schultz M.G.
        Exercise blood pressure and cardiac structure: a systematic review and meta-analysis of cross-sectional studies.
        J Sci Med Sport. 2021; 24: 925-930
        • Caselli S.
        • Mango F.
        • Clark J.
        • Pandian N.G.
        • Corrado D.
        • Autore C.
        • et al.
        Prevalence and clinical outcome of athletes with mitral valve prolapse.
        Circulation. 2018; 137: 2080-2082