Mitral Regurgitation: Structure and

Function

Linda D. Gillam, MD, MPH, FACC, FASE

Morristown Medical Center
Chair Cardiovascular Medicine
Atlantic Health System
No Disclosures
 Leaflet
Anatomy

Function (grading
stenosis and
regurgitation)
 Functional Disturbance
Why? How bad is it?
(leaflet/cusp (grading)
Motion)
Collateral
Damage?

Management
Decision

Anatomic Change Disease

Surgical View
Transthoracic Echo
Transesophageal Echo (TEE)
J Am Soc Echocardiogr 2013;26:921-64.
MV Transgastric View
(Basal Transgastric View)
 TEE > TTE
3D very helpful

BUT
Can learn a lot
from 2D TTE
What about 3D?
3D TEE
Mitral Valve is More than Leaflets
Chordae
 Classification (>100 chords)
• Primary (marginal)
– Free margins of the leaflets
– Chordal free zone (A2, P2)
– Thinner, maintain competence
– Severe MR if they rupture
• Secondary (basal, rough zone)
– Under surface of the leaflets
– Maintain LV geometry
• Tertiary
– Originate from free wall and trabecular
– Insert exclusively into PML
– Role??
• Commissural chorde
 Strut Chordae

• Secondary chordae
inserting into anterior
leaflet only (4 and 8 o’clock)
Commissural Chordae
Don’t forget the annulus

Saddle shaped, dynamic

 Mitral Regurgitation
Function
The (Other)Carpentier Classification
www.ecocardiografia.info/didat_Carpentier.htm
 Leaflet motion is normal

Or perforation, superimposed vegetation….

Mitral valve prolapse or flail
Motion restricted in systole and diastole
(May be associated with stenosis)

Rheumatic Disease
 Motion restricted in systole

Leaflet tethering due to LV

dysfunction/remodeling ± annular remodelling
 Leaflet motion is normal

Or perforation, superimposed vegetation….

 Endocarditis

Anatomy can identify the disease

Rheumatic MV Disease
Leaflet tethering due to LV dysfunction/remodeling ± annular
remodelling
 Functional regurgitation
• Occurs in the presence of anatomically normal
leaflets and chords when there is left
ventricular dysfunction
– Non-ischemic
– Ischemic
Apical Tethering is the Marker of
Functional Mitral Regurgitation
Normal Apical Tethering
Pathophysiology
LV Systolic function
Papillary muscle displacement
Papillary muscle function
Annular dimension
Impact of Loading Conditions

LV Systolic Function
Papillary muscle displacement
Papillary muscle function
Annular dimension

Loading
Conditions
Effect of Systemic BP
Quantitation of Mitral Valve Tenting in Ischemic MR
by Transthoracic Real-time 3D Echo

normal

Tenting volume: 4.6ml

Tenting height: 9.2mm
Watanabe N, Ogasawara Y, Yoshida K et. al J Am Coll Cardiol 45:763-9, 2005
Are the leaflets truly normal?
 Summary
• Use echocardiography to its fullest
• In describing anatomy recognize that there is
more than just anterior and posterior leaflets
– Use Carpentier nomenclature
• In describing function reference the
Carpentier classification system
• Use this to provide a complete picture!