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MORPHOLOGY OF THE MITRAL VALVE. M. Kuduvalli. ELEMENTS OF MITRAL VALVE APPARATUS. Annulus Leaflets Subvalvar apparatus - Chordae tendinae - Papillary muscles. MITRAL ANNULUS.

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elements of mitral valve apparatus
ELEMENTS OF MITRAL VALVE APPARATUS
  • Annulus
  • Leaflets
  • Subvalvar apparatus

- Chordae tendinae

- Papillary muscles

mitral annulus
MITRAL ANNULUS
  • Zone of junction which serves as attachment to the muscular fibres of the atrium, ventricle, and attachment of the mitral valve
  • Attached to two fibrous trigones

-The right fibrous trigone which forms a dense junction between the mitral, tricuspid and aortic (non-coronary cusp) annuli, and the membranous septum

-The left fibrous trigone which lies between the aortic (left cusp) and the mitral annuli

  • Between the two trigones, the mitral valve is in continuity with the aortic wall and there is no fibrous mitral annulus in this region
mitral annulus6
MITRAL ANNULUS
  • Mitral annulus is a dynamic structure
  • Has a sphincter like function, effectively decreasing the valve area by about a quarter during systole
  • This is secondary to contraction and relaxation of the basoconstrictor muscles (bulbospiral and sinospiral)
  • Dilatation of the annulus occurs posteriorly
mitral leaflets
MITRAL LEAFLETS
  • Form a continuous veil attached to the circumference of the mitral annulus
  • Free edge hangs into the LV, and is split by indentations
  • Two well defined and constant indentations:

- Anterolateral commissure

- Posteromedial commissure

mital leaflets
MITAL LEAFLETS
  • Commissural areas (identified by presence of commissural chordae) divide the continuous mitral veil into two leaflets:

- Anterior (aortic) leaflet

- Posterior (mural) leaflet

mitral leaflets10
MITRAL LEAFLETS
  • Covered with endocardium
  • Distinct ridge on atrial side which

- defines line of leaflet closure

- separates leaflets into two zones

- rough zone distal to the ridge

(represents surface of coaptation)

- clear zone proximal to the ridge

anterior mitral leaflet
ANTERIOR MITRAL LEAFLET
  • Semicircular or triangular
  • Attached to around 3/8th of circumference of the mitral annulus
  • Has common attachment to the cardiac skeleton with

- left coronary cusp

of aortic valve

- half of non-coronary cusp

anterior mitral leaflet13
ANTERIOR MITRAL LEAFLET
  • Rough zone receives the chordae tendinae
  • Forms boundary dividing the outflow and inflow tracts of the left ventricle.
anterior mitral leaflet14
ANTERIOR MITRAL LEAFLET
  • Direct continuity between AML and the aortic wall
  • Gap between aortic and mitral valves is filled with an inter-valvular septum. Fibrous mitral annulus is absent here

1.Intervalvular

septum

2. AML

3. PML

posterior mitral leaflet
POSTERIOR MITRAL LEAFLET
  • Quadrangular in shape
  • Attached to around 5/8th of the circumference of the mitral annulus
  • Margin has two indentations, forming three scallops:

- Anterolateral

- Middle

- Posteromedial

  • Cleft chordae insert into these indentations
posterior mitral leaflet17
POSTERIOR MITRAL LEAFLET
  • Additional third zone, k/a basal zone, which is between the clear zone and the annulus. It receives insertion of the basal chordae
  • Basal zone is most obvious in the middle scallop since the majority of basal chordae insert here
subvalvar apparatus papillary muscles
SUBVALVAR APPARATUSPAPILLARY MUSCLES
  • Two groups of LV papillary muscles

- Anterolateral

- Posteromedial

  • Each group supplies chordae to their respective halves of both leaflets
  • Arise from the anterior and posterior walls of the left ventricle respectively
subvalvar apparatus papillary muscles19
SUBVALVAR APPARATUSPAPILLARY MUSCLES
  • May have one or more bellies each. Anterolateral usually has one
  • Tip points towards the respective commissure
subvalvar apparatus chordae tendinae
SUBVALVAR APPARATUSCHORDAE TENDINAE
  • Fibrous strings that originate from tiny nipples on the apical portion of the two papillary muscles
  • Majority have branching pattern, either soon after their origin from the papillary muscles, or just before their insertion into the leaflets
commissural chordae
COMMISSURAL CHORDAE
  • Two in number, one for each commissure, with similar names
  • Arise as a main stem which branches radially to insert into the free margins of the commissural regions
  • Their attachment defines the extent of the commissural areas
chordae of the a m l
CHORDAE OF THE A.M.L
  • Typically splits into 3 cords soon after its origin from the papillary muscles
main chordae of the a m l
MAIN CHORDAE OF THE A.M.L.
  • Two in number, one from each papillary muscle
  • Inserted at 4-5 O’clock posteromedially and 7-8 O’clock anterolaterally
other chordae of the a m l
OTHER CHORDAE OF THE A.M.L.
  • Paramedial chordae

- Insert near the middle of the free edge

  • Paracommissural chordae

- Insert between the main chordae and the commissural chordae

chordae of the p m l
CHORDAE OF THE P.M.L.
  • Basal chordae

- Unique to the PML

- Arise directly as single strands from the left ventricular free wall or from the small trabeculum carnae

  • Rough zone chordae tendinae

- Similar to AML chordae, but shorter and thinner

  • Cleft chordae

- Insert into indentations on the PML

blood supply of the mitral valve
BLOOD SUPPLY OF THE MITRAL VALVE
  • Mitral leaflets and chordae are avascular
  • Papillary muscle supply

- Anterolateral supplied by LAD and in addition, by the Diagonal or an OM from the Circumflex

- Posterolateral variably supplied by branches of either the Lt. Circumflex or the RCA

types of mitral valve pathology
TYPES OF MITRAL VALVE PATHOLOGY
  • Type I: Normal leaflet motion

- Annular dilatation

- Leaflet perforation

  • Type II: Leaflet prolapse

- Chordal rupture

- Chordal elongation

- Papillary muscle rupture

- Papillary muscle elongation

  • Type III: Restricted leaflet motion

- Restricted opening: Commissural fusion, leaflet and chordal thickening

- Restricted closure: Excess tension on chordae during systole

rheumatic mitralvalve morphology
RHEUMATIC MITRALVALVE MORPHOLOGY
  • Can manifest as

- Stenosis

- Regurgitation

- Mixed

  • Three primary pathological processes

- Leaflet thickening

- Chordal thickening, shortening and fusion

- Coaptation of the edges of the leaflets, especially near the commissures

rheumatic mitralvalve morphology35
RHEUMATIC MITRALVALVE MORPHOLOGY
  • Leaflet thickening can progress to:

- Calcification, first of leaflet, and then peri-annular

- Retraction, leading to combined stenosis and regurgitation

  • Subvalvar apparatus involvment may lead to different degrees of subvalvar fusion
ischemic mitral valve disease
ISCHEMIC MITRAL VALVE DISEASE
  • Due to a combination of left ventricular wall akinesia or dyskinesia and ischemia of the papillary muscle itself, affecting the integrity of the subvalvar apparatus
  • Papillary muscle necrosis can lead to rupture either at its attachment at the base to the LV wall or at its tip near the chordal attachments
  • Leaflets and chordae are avascular structures, and are not directly involved in ischemic MR
myxomatous degeneration morphology
MYXOMATOUS DEGENERATION MORPHOLOGY
  • Chordal elongation and rupture
  • Thickening of mitral leaflets
  • Redundancy of mitral leaflets, billowing into the left atrium in systole
  • Degeneration and abnormal collagen synthesis in the region close to the chordal attachments
infective endocarditis of mitral valve
INFECTIVE ENDOCARDITIS OF MITRAL VALVE
  • Leaflet involvement, with vegetation formation and subsequent destruction of the leaflet
  • Thickening and healing around chronic leaflet perforations
  • Annular and periannular abscesses, subsequently involving the aortic valve
  • Chordal detachment due to destruction of leaflet edges
  • Rupture of chordae and papillary muscles due to their primary involvement
other diseases involving mitral valve
OTHER DISEASES INVOLVING MITRAL VALVE
  • Marfan’s and Ehler-Danlos syndromes

- Annular dilatation

- Chordal elongation

  • Idiopathic calcification of the mitral annulus

- particularly in the posterior area, with calcification extending into the LA

- seen more frequently in elderly women

other diseases involving mitral valve40
OTHER DISEASES INVOLVING MITRAL VALVE
  • HOCM – associated with MR

- Distortion of the AML from contact with the hypertrophic IVS during systolic anterior motion of the AML

- Dilatation of the LV and the annulus in long standing HOCM