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Mitral valve anatomy for Transcatheter techniques Jean-­‐François OBADIA Cardiothoracic and Vascular Surgery Department Hôpital Louis Pradel LYON -­‐ France OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History 1)  Ring 2)  Leaflets + Atrium + Ventricle 3)  Subvalvular apparatus British Heart Journal, 1978, 40, 351-366
Ring Anatomy of human mitral valve in adult cadaver
and comparative anatomy of the valve
Leaflets --
British Heart Journal, 1978, 40, 351-366
ROBERT WALMSLEY
From The Department of Anatomy and Experimental Pathology,
Theof mitral
University,
St Andrews, Scotland
valve
Comparative anatomy
359
___
Comparative anatomny of mitral valve
355
SUMMARY A comparative anatomical study of the mitral ring and the 2 major mitral cusps of 12 adult
Aorta
mammals, including man, has been made. Two 25 mm thick sections
of 2 adult human
thoraces were cut
Lef t
to show the position and orientation of the adult mitral valve as it lies in the chest atrium
of
the cadaver. Thin
sections of hearts and valves were prepared so that the structure and basal attachments of the cusps could
I
be examined microscopically.
Chordae In most human hearts there is no distinctive, well-defined fibrous thickening or ring at the basal
attachment of the aortic (anterior) mitral cusp: the mitral 'ring' is therefore considered to be usually
Outflow
2
incomplete anteriorly. This is consistent with the findings in the hearts
tract of all other mammals examined.
left
*The posterior part of the ring is interposed between the myocardium
of
left
atrium
and
left
ventricle
ventricle
and corresponds to the region of the attachment of the mural (posterior) cusp
of the mitral valve. In
./
most mammals, including man, this part of the ring is a well-defined band of collagen: in a few mammals,
i. collagen. The relation of the free
wall
including the sheep, the ring is represented by a thin lamina of loose
3
.
of '.the
left ventricle to the posterior part of the ring is of functional significance as it is the ventricular
the ring occurring posthat is responsible
the
the Andrews,
circumference ofScotland
myocardium
major changes inSt
andConclusion Experimental
Pathology,
TheforIn the
University,
aortic (anterior) mitral
the cardiac cycle.
ruminant ungulates,
the sheep and ox, the
teriorly during
cusp has an attachment that is common to it and the related cusps of the aortic valve.
isentire
cuspof thehas
two zonesman.whose
structure
anleftexpression
of their function. There is in each cusp a
heart, the
through the
section has
Oblique section
Fig. 3 Each
OBADIA Jean-­‐François
heart of a 50-year-old
The
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ummit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » 10 % an mitral valve in adult cadaver
anatomy of the valve
t,
o.1
*i.
A
l4b
proximal part of the ascending aorta, the ventricular septum, and the right ventricle. Between the left coronary aortic
Fig. 7 Mitral valve of a rabbit. Though the lamina fibrosa of the mitral
History Ring Leaflets Chordae positions nor is one of the leaflets “septal”. The septal leaflet is
characteristic of the tricuspid valve whereas neither of the
mitral leaflets is attached to the septum. The corresponding
terms for anterior and posterior are “aortic” and “mural”. It is
the aortic leaflet that is in fibrous continuity with the aortic
valve (figs 1B, 2B, and 3). The aortic leaflet has a rounded free
edge and occupies a third of the annular circumference,
whereas the other leaflet is long and narrow, lining the
remainder of the circumference (fig 4A). The aortic leaflet
hangs like a curtain between the left ventricular inflow and
the adult heart. Therefore, there are no clear cut
between the two leaflets. Furthermore, the free ed
mural leaflet is often divided into three or more s
segments described as lateral, middle, and medial or
terms like P1, P2, and P3.10 Although three scallops
common, the scallops are not equal in size. Rangna
colleagues11 found the middle scallops to be larg
majority of hearts (fig 4A). Victor and Nayak12 likene
between scallops to the pleats of a skirt. When the m
let is deformed in a floppy valve, the middle scallop i
be prolapsed.
Normally, the valvar leaflets are thin, pliable, tra
and soft. Each leaflet has an atrial and a ventricula
(fig 5A). When viewed in profile, two zones
distinguished in the aortic leaflets and three zon
mural leaflet according to the insertions of the t
cords (fig 5B,C). In both leaflets, there is a clear zo
devoid of cordal attachments. Nearer the free edge,
surface is irregular with nodular thickenings. This i
thickest part, corresponding with the line of closur
free margin. Tendinous cords attach to the undersi
area described as the leaflet’s rough zone. The roug
broadest at the lowest portions of each leaflet b
The shortest distance between
mitral
annulus andor
thecommissure,
coronary arteriesof
occurred
at Point
towardthethe
periphery,
the closure
while the longest distance occurred at Point 5 (7.78 ± 2.61 mm), as demonstrated in Figure
basal zone that is found only in the mural leaflet is
mal area that has insertions of basal cords to its v
surface. Being distant from the ventricular wall,
leaflet does not have attachments to basal cords. I
Figure 3 A dissection showing the left (L) and right (R) fibrous
valve closure, the two leaflets meet each other snugly
trigones revealed by removing the left and non-coronary aortic
rough zone and free edge in apposition but at an an
sinuses. The trigones are expansions of fibrous tissue at either end of
smooth zone (fig 6A).
the area of aortic–mitral valvar continuity. The right fibrous trigone
When the closed valve is seen in profile, the maj
together with the membranous septum forms the central fibrous body.
the closure line lies below the plane of the atriov
The diagrams represent two of the
cases reported
in the work
by data was
Statistical
analysis
of the
achieved using the Student-Newman-Keuls
5
junction rising toward the commissures at the periph
Angelini and colleagues. They show the variation in completeness of
The data are presented as means and standard-deviations. A p-value < 0.05
the so-called valvar annulus (green areas).
so that the atrial surface of the leaflets has a s
The Ring is not a Ring Conclusion OBADIA Jean-­‐François
The study was approved by the Ethics Committee on Research of the Federal
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » A Study of Functional Anatomy of Aortic-Mitral Valve
Coupling Using 3D Matrix
Transesophageal Echocardiography
History 26
Federico Veronesi, PhD; Cristiana Corsi, PhD; Lissa Sugeng, MD, MPH; Victor Mor-Avi, PhD;
Enrico
G. Caiani,
PhD; 2009
Lynn Weinert, BS; Claudio Lamberti, MS; Roberto M. Lang, MD
Circ Cardiovasc
Imaging
January
Ring Leaflets Chordae Veronesi et al
Functional Anatomy of Aortic-Mitral Va
Circ are
Cardiovasc 009;2:24-­‐31 Background—Mitral and aortic valves
known to beImaging. coupled via 2
fibrous
tissue connecting the two annuli. Previous
studies evaluating this coupling have been limited to experimental animals using invasive techniques. The new matrix
Table 3.
array transesophageal transducer provides high-resolution real-time 3D images of both valves simultaneously.
We Percentage of Inter- and Intr
Principal Index
sought to develop and test a technique for quantitative assessment of mitral and aortic valve dynamics and coupling.
Methods and Results—Matrix array transesophageal (Philips iE33) imaging was performed in 24 patients with normal
Intraobserver,
valves who underwent clinically indicated transesophageal echocardiography. Custom software was used to detect
and
ED projected area
9.5"6.6
track the mitral and aortic annuli in 3D space throughout the cardiac cycle, allowing automated measurement of changes
Maximum projected area
4.0"3.0
in mitral and aortic valve morphology. Mitral annulus surface area and aortic annulus projected area changed
Minimum
projected
area
4.0"4.0
reciprocally over time. Mitral annulus surface area was 8.0!2.1 cm2 at end-diastole and decreased to 7.7!2.1 cm2 in
ED MA-AoA2 angle
2.0"1.6
systole, reaching its maximum (10.0!2.2 cm2) at mitral valve opening. Aortic annulus projected area was 4.1!1.2
cm
2
ES
MA-AoA
angle
2.8"3.8
at end-diastole, then increased during isovolumic contraction reaching its maximum (4.8!1.3 cm ) in the first third of
2
ED
MA-AoA
distance
3.7"2.1
Figure
2.
A,
Selection
of
anterior
and
posterior
MA
systole and its minimum (3.6!1.0 cm ) during isovolumic relaxation. The angle between the mitral and aortic annuli
points
on
a
cut
plane
representing
3-chamber
NC
annulus
length
8.9"6.2
was maximum (136!13°) at end-diastole and decreased to its minimum value (129!11°) during systole.
view.
B,
Selection
of
AoA
points.
C,
Automatically
Left matrix
annulus length
8.5"9.6
Conclusions—This is the first study to report quantitative 3D assessment of the mitral and aortic valve dynamics from
displayed
aortic valve
short
axisThis
cut plane
array transesophageal images and describe the mitral-aortic coupling
in a beating
human
heart.
abilityonmay have
impact
Right
annulus length
9.6"6.7
which interatrial
dot) and coaptation
point
on patient evaluation for valvular surgical interventions and prosthesis
design. (green
(Circ Cardiovasc
Imaging.
2009;2:24-31.)
Data are reported as mean"SD; n#10.
(red dot) are manually identified. D, Computed MA
Key Words: 3D echocardiography ! imaging ! mitral valve
aortic
coupling
(cyan) !and
AoA valve
(red, noncoronary
cusp;valve
orange,
! aortic-mitral
left cusp; yellow, right cusp) splines on RT3DE vol- anterior mitral leaflets, and was cha
shape with its highest point in the mid
ume rendering.
MA,which
adjacent to the fibrous aortic cur
3–5
he mitral and aortic valves are coupled via fibrous tissue
or by a low spatial resolution,
cardiac cycle,
Our
analysis technique allowed us to p
connecting the two annuli. An in-depth understanding of
limits the visualization of valve morphology during dyin a beating human heart 3D measurem
2
the normal mitral-aortic valvular coupling and the ability to
namic assessment.
length of the free edges of the cusps, the
accurately assess changes in different disease states may be
Clinical Perspective see p 31 point above the AoA basal plane, as w
important, particularly in the context of valvular surgical
height. Several animal studies using inv
Because the motion of the aortic valve complex is even
planning and postsurgical assessment. However, this coudifferences in the motion patterns of th
more difficult to characterize, few studies have addressed
in
pling is difficult to evaluate using 2-dimensional imaging
es.9,22 We did not find the exact same as
4. Wiggels
blood
detail the functional anatomyFigure
of this
valve in
3D.pressure
These diagram (top), in correspontechniques because of the 3-dimensional (3D) anatomy ofth
our
human
study,AoA
probably
because
dence
with
measured MA
area,
projected
andm
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« chircardio-­‐lyon.org » area of
T
Conclusion OBADIA Jean-­‐François
The Effect of Surgical and Transcatheter Aortic
Valve Replacement on Mitral Annular Anatomy
History ADULT CARDIAC
Ring Mathieu Vergnat, MD,* Melissa M. Levack, MD,* Benjamin M. Jackson, MD,
Joseph E. Bavaria, MD,
Howard
Herrmann, MD, Albert T. Cheung, MD,
VERGNAT
ET AL C. 615
616
VERGNAT
AL
Ann Thorac Surg
TAVR PRESERVES
MITRALET
VALVE
ANATOMY
Stuart
J. Weiss,
MD,
PhD,
Joseph
H.
Gorman III, MD, and Robert C. Gorman, MD 2013;95:614 –20
TAVR PRESERVES MITRAL VALVE ANATOMY
Ann Thorac Surg 2013;95:614–20 Departments of Surgery, Medicine, and Anesthesia, and Gorman Cardiovascular Research Group, University of Pennsylvania,
Philadelphia, Pennsylvania
ADULT CARDIAC
ally gated full-volume imrdiac cycles at a frame rate
D data sets, color Doppler
the degree of mitral regur-
the University of Pennsylrd.
Conclusion OBADIA Jean-­‐François
ADULT CARDIAC
ADULT CARDIAC
tems, Munich, Germany) to assess regional and global
Background. The effect of aortic valve replacement on
annular geometry.
three-dimensional mitral annular geometry has not been
Results. Mixed between-within analysis of variance
well described. Emerging transcatheter approaches for
showed no differences between TAVR and AVR groups
aortic valve replacement employ fundamentally different
in any of the mitral annular geometric indices preoperamechanical techniques for achieving fixation and seal of
Leaflets tively. However, postoperative analysis did demonstrate
the prosthetic valve than standard surgical aortic valve
618
VERGNAT
ET ALThis study compares the immediate impact
Ann Thoracopen
Surg
an effect of AVR on geometry. Patients undergoing
replacement.
TAVR PRESERVES MITRAL VALVE ANATOMY
2013;95:614 –20
AVR had significant decrease in annular height, septoof transcatheter aortic valve replacement (TAVR) and
lateral diameter, mitral valve transverse diameter, and
standard surgical aortic valve replacement (AVR) on
mitral annular area after valve replacement (p < 0.006).
mitral annular anatomy.
Similar changes were not noted in the TAVR group.
Methods. Real-time three-dimensional echocardiograFig 2. Illustrative
example of
geometric parameters.
depictingMitral
the measured
parameters
used for analysis.
(A, preB) CalConclusions.
annular
geometry
is better
phy was performed
in patients
undergoing
TAVRMitral
usingannular modeling
Rotational template used for segmentation of the mitral valve
annulus.
Annularheight
points are placed
every
culation
of the annular
and septolateral
(C) Calculation for commissural width (CW) and mitral transverse diameby TAVR than by AVR. Thus, TAVR may be a
the Edwards
Sapien
valve (n (AH)
! 10
[Edwards diameter
Life- (SL).served
ng-axis view around the circumference of the annulus. (B)ter
Segmentation
anterior
and posterior
(MTD). (AC of
" the
anterior
commissure;
Mid-AA " mid anterior annulus; Mid-PA " mid posterior annulus; PC " posterior commissure.)
more physiologic approach to aortic replacement.
sciences,
Irvine,
CA])
or AVR
! 10) for
severe aortic
t 1-mm intervals along the length of the mitral
valve. (AA
# anterior
annulus;
AC (n
# anterior
commis(Ann Thorac Surg 2013;95:614 –20)
stenosis.
Mitral
annular
geometric
indexes
were
meaAoV # aortic
valve; LA # left atrium; LV # left ventricle; LVOT # left ventricular outflow tract; MVO #
Chordae Edwards
valve
Irvine,
CA), and
between-within
analysis of (Tomtec
variance was
used to compare
the
© Sapien
2013 by
The(Edwards
SocietyLifesciences,
of Thoracic
Surgeons
sured using
Tomtec EchoView
Imaging
Sysnnulus; PC # posterior commissure; PML # posterior
mitral leaflet.)
2 received a 26 mm Edwards Sapien valve. All patients
eight MV annular outcome variables among patients underundergoing AVR received a bioprosthetic valve (Carpentiergoing TAVR and AVR, before and after intervention. To
Edwards Magna pericardial valve, n " 7; Sorin MitroFlow,
minimize the likelihood of inflating type I error and to account
squares plane of the
data-point
cloud forvariables,
the annulus
was of 0.006 or less
Milan,
n " 2; and St Jude Trifecta, St. Paul, MN, n " 1).
for
the
eight
dependent
a p is
value
urgical
aortic
valve
replacement
(AVR)
the
estabPatient
andItaly,
Methods
aligned to the x-y plane.
Under these
conditions,
Of these, 4 patients received a 21-mm valve, 3 received a
(approximately
0.05 !geometric
8) was taken
to be statistically signifitherapy
forpoint
symptomatic
aortic
stenosis;
howthe annular lished
height
forIfeach
(zn)hoc
waspaired
plotted
as awere
Patients
and valve,
Image
Acquisition
23-mm
and
3 received a 25-mm valve.
cant.
indicated,
post
t tests
performed
transcatheter
aortic
valve
replacement
(TAVR)
has
functionever,
of rotational
position
on
the
annulus.
A
number
of
between preprocedure and postprocedure groups, and unPatients
undergoing
surgical treatment for severe or
recently
been
shown
to demonstrate
acceptable
early
and
Comparison of Mitral Regurgitation
anatomic
landmarks
were
septum
was idenpaired
t identified.
tests were The
performed
between
TAVR and AVR
critical
aortic
stenosis
were selected for inclusion in this
outcomes
in high-risk
patients
with symptified asintermediate
the anterior
horn
of the
annulus
at the
aorticperformed
valve.
groups.
All
statistical
analysis
was
using SPSS
InPatients
the TAVR
cohort, a50%
of patients
had[Sapien;
mild MR,
40%
study.
received
TAVR
(n ! 10
Edtomatic
severe
aortic
stenosis
The effect
of either
software
(SPSS
Inc, Chicago,
had moderate MR, and 10% had severe MR before valve
The lateral
annulus
was
identified
as [1–3]
the IL).
middle
of the
wards Lifesciences, Irvine, CA]) or standard open AVR
technique
for aortic valve
replacement
on mitral valve
implantation. In comparison, 20% of patients in the AVR
posterior
annulus circumference.
The
septolateral diameter
(n ! 10). The
TAVR
valve
sizing was
determined
by the
Fig 5. (A) (MV)
Comparison
of select geometric
indices
in transcatheter
aortic
valve implantation
versus
replacement
(AVR).
three-dimensional
(3D)
anatomy
has
not
been
group(TAVI)
had no
MR,aortic
40% valve
had mild
MR, and
40% had
was defined as theResults
distance between these two points. With
discretion
ofand
themitral
surgeon
based
on
two-dimensional
(2D)
Patients undergoing
AVR had significant decreases in annular height,
septolateral
diameter,
annular
area
relative
to their initial
th
described.
moderate
MR.
The
degree
of
MR
remained
unchanged
the annular
rotated
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arcelona -­‐ 19-­‐20
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such
that the
were June 2015
S
Figure 4. In this patient, the Cx courses between the CS and the MVA (A, 4-chamber view). The volume-rendered reconstruction (B)
and the reconstructed MVA level (C) show that the Cx courses inferiorly to the CS over a long distance. Percutaneous mitral annuloplasty may result in compression of the Cx.
History Noninvasive Evaluation of Coronary Sinus Anatomy and Its
Of note, when the LCX coursed inferiorly to the CS,
minimal distances between the CS and the MVA were
Relation tostudied.
Valve
the the
number ofMitral
marginal branches
of the LCXAnnulus
was larger.
assessed at the proximal and the distal CS and appeared to be
Tops et al
However,
no dataof
on Coronary
the minimal distance
between
the CS
highly
variable Annulus
(Table 2). Although this
finding confirms the
MSCT
Sinus
and
Mitral
Valve
1429
Implications forandPercutaneous
the LCX were provided. Mitral Annuloplasty
previous anatomic studies, the use of different reference
These anatomic observations have previously been conpoints makes a direct comparison between the present study
firmed with electron-beam computed tomography.15,16 Mao et
and previous in vitro studies difficult. Importantly, in patients
MD;
Nico
Van
dereported
Veire,
MD,
PhD;
D. Schuijf,
MSc;
detheRoos,
TABLE 2. QuantitativeLaurens
AnalysesF.ofTops,
the CS
and
the R.
MVA
in
TABLE
3. Joanne
Quantitative
ofAlbert
the CS
the MVA
inbetween the CS and the
that the
LCX coursed
inferiorly to the Analyses
CS in
al15the
with
severe
MR,and
minimal
distance
MD,
PhD;
Ernst
E.
van
der
Wall,
MD,
PhD;
Martin
J.
Schalij,
MD,
PhD;
Jeroen
J.
Bax,
MD,
80.8%
of
the
studied
patients.
Furthermore,
it
was
demonmay Regurgitation
increase PhD
significantly. In particular, the use of
3 Patient Groups
Patients With and Without SevereMVA
Mitral
strated that
the overlapping
segment
the CS and
the LCX
percutaneous
Tops et al
MSCT
of Coronary
Sinus
andofMitral
Valve
Annulus
1427 mitral annuloplasty may be not feasible in
was !30has
mm been
in 17.8%
of the cases.
once againtonosurgical
patients
where the
CS
Controls
CAD
HFannuloplasty
Patients
Without
Patients
With along the left atrial wall
Background—Percutaneous
mitral
proposed
as However,
an alternative
annuloplasty.
Incourses
this
data
on
the
minimal
distance
between
the
CS
and
the
LCX
(Figure
5).
(n#35)
(n#36)
(n#34) sinus (CS)
P* and its relation with the mitral valve annulusSevere
MRand theSevere
MR
respect,
evaluation
of the coronary
(MVA)
coronary
were provided.
It should be noted that in the present study images were
(n#90)
(n#15)
P*
arteries
is
relevant.
The
feasibility
of
evaluating
these
issues
noninvasively
with
multislice
computed
tomography
was
In the present study, the LCX coursed inferiorly to the CS
Minimal distance between CS and MVA
routinely reconstructed at 75% of the RR interval. However,
in 68% of the patients,
with adistance
minimal distance
between
the MVA the diameter and the distance between the CS and the MVA
determined.
between
CS and
At MVA level
4.4!2.2
4.9!2.7
6.2!3.4†
0.019the LCX ofMinimal
CS and
1.3"1.0years),
mm. The64-slice
close relation
between computed
may vary tomography
during the cardiac
cycle. Nevertheless, the present
Methods and Results—In 105 patients (72
men, age 59!11
multislice
was
At MVA
level
4.8!2.5
7.3!3.9
0.005
the0.006
CS and the LCX may
limit the
use of percutaneous mitral
study shows that MSCT
can accurately
depict CS anatomy
At proximal CS
7.6!1.6for noninvasive
7.9!2.1
9.3!2.8†
performed
evaluation ofvalve
coronary
artery
disease.
Thirty-four
patients
with
heart
failure
and/or
severe
annuloplasty, particularly
when
the
LCX
courses
infeand its relation with the
MVA and thereby
provides important
Figure
1.
Volume-rendered
reconstructions
At
proximal
CS
8.1!2.4
9.3!1.9
0.019
At distal CS
7.3!3.3
8.5!3.2
$0.001
mitral
regurgitation
were 10.7!3.0‡§
included. Three-dimensional
reconstructions
and standard
planes
used
riorly to the CS over
a longshow
distance
4).
information
patients
who to
are being considered for percuthe (Figure
relation
between orthogonal
the CS and
the
left onwere
Leaflets At distal
CS
8.3!3.1
12.1!3.6
$0.001
the MVA and circumflex
artery.
In 71 artery
patients
the mitral
circumflex
artery
taneous
annuloplasty.
circumflex
coronary
(Cx).(68%),
A, The
Cx
CS diameter at proximal CSassess CS anatomy and its relation with CS
and MVA
courses
deeper
than
the
CS
and
lies
between
coursed
between
the
CS
and
the
MVA
with
a
minimal
distance
between
the
CS
and
the
circumflex
artery
of
MVA have
diameter
(2-chamber
40.2!4.7
44.3!3.3
0.001
Several
addressed
the relationview)
between
AP diameter
10.5!2.7
9.7!2.3
9.9!3.3
0.5 anatomic studies
the CS and the mitral valve annulus.Implications
B, The Cx for Percutaneous Mitral Annuloplasty
7–9 Shinbane et al7 studied 10 normal
andatrial
the MVA.
1.3!1.0 mm. The CS was located along the
theCS
left
wall,
rather
than
along
the
MVA,
in
the
majority
of
the
patients
courses
superiorly
to
the
CS.
MVA diameter (4-chamber view)
35.8!4.4
0.002
The present study 39.9!4.4
shows the feasibility
of the noninvasive
SI diameter
15.0!3.2
0.3cadaver
adult
and level
reported
distances
(ranging
from 14.0!3.0
90% at the 14.2!3.0
level of the MVA
to 14%hearts
at the
ofvariable
the distal
CS).between
The minimal
distance
theand its relation with the MVA
evaluation
of thebetween
CS anatomy
the
CS
and
the
MVA
along
the
course
of
the
CS.
Mean
MVA
perimeter
118.1!12.6
127.6!14.7
0.020
1430
Circulation
20,was2007
CS diameter
at distal CS CSMarch
and MVA
5.1!2.9 mm. In patients
with severe mitral regurgitation, the minimal distance
between
CS and
and the
coronarythe
arteries.
In previous in vitro7–9 and in
distances between the CS and the MVA were 14.1"3.1 mm,
15,16 studies, the
Total
CS
length
110.1!16.6
128.6!14.6
vivo
relation
between$0.001
the CS, the MVA, and
the MVA
was significantly
greater as compared
withand
patients
severe ofmitral
(mean 7.3!3.9 mm
AP diameter
3.9!0.7
3.9!0.6
4.0!0.7
0.7 mm,
10.2"4.9
10.7"3.5without
mm at distances
20, 40,regurgitation
and
Circula0on. 2007;115:1426-­‐1432 Ring 60 mm, respectively,*As
from
the ostium
the CS. El- U test.
versus
4.8!2.5 3.9!0.7
mm, P"0.05).
assessed
withofMann-Whitney
4.1!0.9
4.0!0.9
0.7
8 studied the distances between the CS and the
Maasarany
et
al
Conclusion—In the majority of the patients, the CS courses superiorly to the MVA. In 68% of the patients, the circumflex
MVA in 32 normal cadaver hearts. Distances were assessed
Total CS length
108!12
106!14transluminal
$0.001
artery
courses between
the 126!19‡!
CS andcoronary
the mitral
annulus.
Multislice
computed tomography may provide useful information
history of myocardial
infarction/percutaneous
Dataregions
Analysis
Chordae in 6 separate
along the course of the CS. Mean
angioplasty/coronary
bypass
grafting,
or a significant
stenosisfor percutaneous
analysis
was performed
a remote
workstation
AP indicates
anterior–posterior;
superior–inferior.
forartery
the SI,
selection
of potential
candidates
mitral
annuloplasty.
(Circulation.
2007;115:1426-1432.)
distance Data
was highly
variable
for
the 6 on
regions;
the postprocessing
shortest
SI diameter
Mitral Regurgitation
in !1 coronary artery on the MSCT scan; group III (heart failure,
Images,
Plymouth, commisMinn). Volume-rendered
*Assessed
by ANOVA with Scheffé post hoc testing.
distance (Vitrea
(5.8 mm)2,
wasVital
observed
at the anterolateral
n!34) included patients with severe
heart
failure imaging
(left ventricular
Key
Words:
mitral
computed
coronary
vessels
3-dimensional
reconstructions
and
standard
were (48%) had no MR,
In the
total
study
population,
50planes
patients
! !P$0.001
! tomography,
!orthogonal
sure ofvalve
the
MVA.
Unfortunately,
nox-ray
data
were
provided
about
†P$0.05ejection
vs controls;
‡P$0.001
vs
controls;
§P$0.05
vs
CAD;
fraction "35%).
usedof to
assess
the anatomy
and (superior/infethe course of the CS and its
the
position
the
CS
in
relation
to
the
MVA
30 patients (29%) had MR grade 1", and 10 patients (9%)
vs CAD.
tributaries. Furthermore, the course of the coronary arteries and the
Data Acquisition
rior/same level). In the largest anatomic study reported,
had dominance
MR grade
MR was
characterized
coronary
artery
(right, 2";
left, or balanced)
was assessed.
In
9
as 3" in 13
distances
CS
Maselli
et al also noted variable
itral annuloplasty is the most commonly
performed
Evaluation
of between
the
CS the
anatomy
its relation
particular,patients
the course
of the LCX
in relation
to the and
CS (inferior
or to the MVA
(12%)
and
4"
and the MVA. At the
level of the
P2 and P3
scallops
ofin
the2 patients (2%). To detect differMultislice Computedsurgical
Tomography
procedure for ischemic mitral regurgitation
and the coronary
may
be of
value
in patients
who are
superior) was determined
(Figure 1).arteries
The axial
slices
were
studied
to
mitral of
valve, mean ences
distances in
between
CS and the MVA
performed
Toshiba
Multislice
Aquilion
system
thethe
anatomic
andofand
quantitative
data Multislice
between patients
5.1!2.9MSCT
mm was
(range
1.41with
to a16.8
Also,
the64relation
the minimal
distance
between
the LCX
the CS.
(MR).
Recently,
amm).
percutaneous
approach
to 5.7"3.3
mitral assess
annuloconsidered
for
percutaneous
mitral
annuloplasty.
mm and 9.7"3.2 mm were reported.
(Toshiba Medical Systems, Tokyo, Japan) with a collimation of
with
and
without
severe
MR,
study
population was
wastime
proposed.
studies
havestudy,
the CS and
the
was
determined
proximal
computed
tomography
(MSCT)
canthe
provide
an accurate
Inand
the Anatomic
present
the
highly variable
relation
between
64"0.5
mmMVA
andplasty
a rotation
of 400 to Validation
500 at
ms,the
depending
on in
the animals
and
Quantitative
Analyses
Conclusion 10
shown
the
feasibility
of
the
percutaneous
transvenous
mitral
the
CS
and
the
MVA
was
assessed
noninvasively
with
evaluation
of
the
anatomy
ofMR
the grade
CS. Recent
divided
into 2long-axis
groups:
patients
with
!2" (n#90)
current was
300the
mACS
at 120
kV.located
Nonionic moreWith the use
the distalheart
CS.rate.
AtThe
thetube
proximal
CS,
was
of noninvasive
reconstructed
2- and
4-chamber
views
and
2–5 In addition, preliminary results
CS
located
more superiorly
to the MVA
in the use
annuloplasty.
of The
the
firstwas
contrast material
(Iomeron 400,
Bracco, Altana Pharma, Konstanz,MSCT.
preliminary
data reconstructions,
suggest
a potential
of4"
MSCT
scanning in
volume-rendered
3-dimensional
relation
be-(n#15).
and
patients
with
MR
grade
3"
or
superiorly
to
the
MVA
in
57
patients
(54%),
more
inferimajority
of the
(ranging
from
at the (Figure
of 2). The
Germany) was administered
in the antecubital
vein, in an amount
oftheannuloplasty
11 courses along the left atrial (LA)
tween
the patients
CS and
the MVA
was90%
assessed
position
of patient, the CS
Figure
5. In annuloplasty.
this
human experience
with percutaneous
mitral
patients
considered
for level
percutaneous
mitral
th at
Figure
4.in
In 7this
the Cx
courses
the
(A,
4-chamber
view).
The
reconstruction
between
the
groups
inthe the
MVA
to CS
14%
theNo
level
ofthe
theMVA
distal
Furthermore,
posterior
wall
rather
MVA. anaOBADIA Jean-­‐François
and
the
total
between
same
Sthe
ummit –and
Brate
arcelona -­‐ 1the
9-­‐20
une 2015
(superior/inferior/same
CS).
volume-rendered
existed
Download this level)
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n «along
(B)
chircardio-­‐lyon.org » orly
level
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80patients
topatient,
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depending
on at
the
scan
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andCS
a in
flow
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6 PMVR inJrelation
todifferences
and
the2
M
REVIEW
European Journal of Echocardiography (2010) 11, i3–i9
doi:10.1093/ejechocard/jeq153
Anatomy of the mitral valve: understanding the
European Journal of Echocardiography (2010) 11, i3–i9
mitral
valve complex in mitral regurgitation
doi:10.1093/ejechocard/jeq153
tional Journal of Cardiology 163 (2013) 242–248
History of Echocardiography (2010) 11, i3–i9
Karen P. McCarthy 1*European , Liam RingJ2ournal , and Bushra
S. Rana 2
ability
round
e venreprethree
l comConclusion onding
A1, A2
1
Cardiac Morphology Unit, Royal Brompton and Harefield NHS Foundation Trust and Imperial College London, Sydney Street, London SW3 6LY, UK; and
2
Department of Cardiology, Papworth Hospital NHS Foundation Trust, Cambridge, UK
Received 16 September 2010; accepted after revision 16 September 2010
Anatomy of the mitral valve: understanding the
mitral valve complex in mitral regurgitation
Imaging the mitral valve requires an understanding of the normal anatomy and how this complex structure is altered by disease states. Mitral
regurgitation is increasingly prevalent. Despite the fall in rheumatic diease, it is the second most common valvular lesion seen in adults in
Europe. In this review, the morphology of the normal and abnormal valve is reconsidered in relation to the key structures, with a view
to aiding the reader in understanding how this might relate to echocardiographic identification of abnormalties.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Mitral regurgitation † Anatomy
Karen P. McCarthy 1*, Liam Ring 2, and Bushra S. Rana 2
Downloaded from by guest on June 13, 2015
ut any
ntricle.
ure of
Ring fibrous
valve.
e from
diately
guards
s with
Leaflets mitral
equal
tendirepreresent
eaflet,
ssures.
e pos- Chordae REVIEW
Introduction
Cardiac Morphology
Unit, Royal Brompton and Harefield NHS Foundation
Trust and
Imperial
College
London,
Sydneycorrect,
Street, London SW3 6LY, UK; and
by clinicians.
Although
neither
description
is anatomically
2
the mitralPapworth
valve (MV)Hospital
requires an
understanding
of the
the terms aortic
and mural leaflets are preferred.3 The mural (posDepartment ofImaging
Cardiology,
NHS
Foundation
Trust, Cambridge,
UK
structure and are referred to as the anterior and posterior leaflets
1
normal anatomy and how this complex structure is altered by
disease states.
MV isafter
composed
structures
Received 16 September
2010;The
accepted
revisionof16several
September
2010
working in synchrony to open during diastole and close in
systole effectively within the high-pressure systemic environment.
Morphological changes of the valve can affect mechanical integrity
resulting in abnormal leaflet closure and regurgitation of blood
back into the left atrium causing loss of ventricular pressure and
forward flow.
Mitral regurgitation is increasingly prevalent. Despite the fall in
rheumatic diease, it is the second most common valvular lesion
seen in adults in Europe.1 Surgical repair should be performed
whenever possible when the likelihood of successful repair is
high. Since retaining the native valve has significant advantages,
including the preservation of left ventricular function and longterm survival.2 In this review, the morphology of the normal and
abnormal valve is reconsidered in relation to the key structures
with a view to aiding the reader in understanding how this might
relate to echocardiographic identification of abnormalties.
terior) leaflet is narrow and extends two-thirds around the left
atrioventricular junction within the inlet portion of the ventricle.
In adults, the mural leaflet has indentations (sometimes called
‘clefts’) that generally form three scallops (segments) along the
elongated free edge. These indentations do not usually extend all
the way through the leaflet to the annulus; if this is seen, then
this is usually associated with pathological valve regurgitation. Carpentier’s nomenclature4 describes the most lateral segment as P1,
which lies adjacent to the anterolateral commisure, P2 is central
and can significantly vary in size, and most medial is P3 segment,
which lies adjacent to the posteromedial commissure (Figure 1).
The semicircular aortic (anterior) leaflet of the MV is much
broader than the mural leaflet, comprises one third of the
annular circumference and has a clear and rough zone (Figure 2).
The distinguishing feature of this leaflet is the fibrous continuity
with the left and non-coronary cusps of the aortic valve and
with the interleaflet triangle between the aortic cusps that abuts
onto the membranous septum.5 The aortic leaflet is also divided
arbitrarily into three regions labelled A1, A2 and A3 corresponding
to the adjacent regions of the mural leaflet (Figure 1).
From the attachment point of each leaflet at the annulus to the
thfree edge, the leaflet is described as having basal, clear and rough
Imaging the mitral valve requires an understanding of the normal anatomy and how this complex structure is altered by disease states. Mitra
regurgitation is increasingly prevalent. Despite the fall in rheumatic diease, it is the second most common valvular lesion seen in adults i
Europe. In this review, the morphology of the normal and abnormal valve is reconsidered in relation to the key structures, with a view
to aiding the reader in understanding how this might relate to echocardiographic identification of abnormalties.
--------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Mitral regurgitation † Anatomy
Normal mitral valve anatomy
OBADIA Jean-­‐FrançoisIntroduction
Leaflets PMVR Summit – Barcelona -­‐ 19-­‐20
June 2015
structure and are referred to as the anterior and posterior leaflet
Download this presenta0on on « chircardio-­‐lyon.org » The American Journal of Cardiology (www.ajconline.org)
Real-Time Three-Dimensional Transesophageal Echocardiography
for Assessment of Mitral Valve Functional Anatomy in Patients
With Prolapse-Related Regurgitation
History Giovanni La Canna, MDa,*, Iryna Arendar, MDa, Francesco Maisano, MDb, Fabrizio Monaco, MDa,
Egidio Collu, MDa, Stefano Benussi, MDb, Michele De Bonis, MDb,
Am J Cardiol 2011;107:1365–1374 , and Heart
Ottavio
Alfieri,
MDb Echocardiography in Mitral Prolapse
Alessandro Castiglioni, MDbValvular
Disease/3D
Transesophageal
Ring The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral
valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography
(2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive paA1,2,3 è for
25 prolapse-related
% tients undergoing
repair
mitral regurgitation using RT3D-TEE, 2DTEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volumerendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data
were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified
prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%),
and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment
localization or commissural lesions), RT3D-TEE correctly identified 58 (96.5%) compared
to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p <
0.0001). Multiplanar reconstruction enabled RT3D-TEE
15 to differentiate dominant
(>5-mm displacement) and secondary (2 to <5-mm displacement) prolapsed segments in
% but with a low predictive
agreement with surgically recognized dominant lesions (100%),
value (34%) for secondary lesions. In addition, owing to the identification of clefts and
subclefts (indentations of MV tissue that extended >50% or <50% of the total leaflet
height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that
which deviated from the standard nomenclature. In conclusion, RT3D-TEE provided more
accurate mapping of MV prolapse than 2D imaging and RT3D-TTE, adding quantitative
recognition of dominant and secondary lesions and MV anatomy details. © 2011 Elsevier
Inc. All rights reserved. (Am J Cardiol 2011;107:1365–1374)
Leaflets Chordae P2 patients
è
8intercommissural
0 %
to when
. Prolapse localization. Per-patient prolapse
localization in 222
according
surgicalline.
findings.
Boxes
number
ofand
monosegment
along
(A) Surgical
viewindicate
of MV
dominant
prolapse
and flailor
of middle
Accurate localization of the valve
lesion
is crucial coaptation
imaging
(2D-TTE
andshowing
2D-TEE)
RT3D-TTE
for
MV scallop of posterior leafl
Conclusion secondary
prolapse
of
medial
segments
of
both
leaflets
(*).
(B1,
B2,
B3)
Cross-section
reference
of cutting plane to guide prolapse measure
sural lesions; solid lines, multisegment
monoleaflet
lesions;
arrowed
solid
lines,
bileaflet
facing
lesions;
arrowed
broken
lines,
nonfacing
bileaflet
planning the surgical repair strategy
for prolapse-related
functional anatomy assessment, using as a standard the
coaptation; (C2) 7-mm displacement (arrow) of middle segment of posterior leaflet (dominant prolapse) with ruptured chordae tendinea
1–3
mitral
regurgitation.
The lesions.
recent displacement
availability
of theofMitrasurgical
findings
in a group
of patients
with
prolapse-related
(arrow)
medialcommissure;
segment
of posterior
leaflet
(secondary
prolapse)
without
prolapse
of medial
dotted lines and asterisk, combined
commissure
and leaflet
ALC # anterolateral
PMC
# posteromedial
commissure;
P1,
P2, segment of anterior leaflet (ma
Figure 1. RT3D-TEE. Cropped multiplanar images of 3D zoom data set of MV for quantitative evaluation of leaflet tip displacement above
OBADIA Jean-­‐François
th
Clip
imposes
a detailed
of
mitral
undergoing
valve repair.
leftdepiction
ventricular
side).
system
further
PMVR Summit –into
Barcelona -­‐ 19-­‐20
June 2015mitral regurgitation
Download this presenta0on on « chircardio-­‐lyon.org » Figure 5. 3D-TEE and anatomic surgical picture showing 3 middle scallops of posterior leaflet (P2a, P2b, P2c) split by complete clefts (arrows). P1 ! lat
scallop, P3 ! medial scallop.
Real-Time Three-Dimensional Transesophageal Echocardiography
for Assessment of Mitral Valve Functional Anatomy in Patients
e American Journal of Cardiology (www.ajconline.org)
With Prolapse-Related Regurgitation
History Giovanni La Canna, MDa,*, Iryna Arendar, MDa, Francesco Maisano, MDb, Fabrizio Monaco, MDa,
Figure 5. 3D-TEE and anatomic surgical picture showing 3 middle scallops of posteriora leaflet (P2a, P2b, P2c) split by complete
clefts (arrows). P1 ! lateral
1372
De Bonis, MDb,
Egidio Collu, MD , Stefano Benussi, MDb, Michele
scallop,Figure
P3 !5.medial
3D-TEEscallop.
and anatomic surgical picture showing 3 middle scallops of posterior leaflet (P2a, P2b, P2c) split by complete clefts (arrows). P1 ! lateral
Ring scallop, P3 ! medial scallop.
Am J Cardiol 2011;107:1365–1374 Alessandro Castiglioni, MDb, and Ottavio Alfieri, MDb
The American Journal of Cardiology (www.a
The aim of the study was to evaluate the additional diagnostic value of real-time 3-dimensional transesophageal echocardiography (RT3D-TEE) for surgically recognized mitral
valve (MV) prolapse anatomy compared to 2-dimensional transthoracic echocardiography
(2D-TTE), 2D-transesophageal echocardiography (2D-TEE), and real-time 3D-transthoracic echocardiography (RT3D-TTE). We preoperatively analyzed 222 consecutive patients undergoing repair for prolapse-related mitral regurgitation using RT3D-TEE, 2DTEE, RT3D-TTE, and 2D-TTE. Multiplanar reconstruction was added to volumeLeaflets rendered RT3D-TEE for quantitative prolapse recognition. The echocardiographic data
were compared to the surgical findings. Per-patient analysis of RT3D-TEE identified
prolapse in 204 patients more accurately (92%) than 2D-TEE (78%), RT3D-TTE (80%),
and 2D-TTE (54%). Even among those 60 patients with complex prolapse (>1 segment
wing 3 middle scallops of posterior leaflet (P2a, P2b, P2c) split by complete clefts (arrows). P1 ! lateral
1372
The American
Journal58
of Cardiology
localization or commissural
lesions), RT3D-TEE correctly
identified
(96.5%) (www.ajconline.org)
compared
to 42 (70%), 31 (52%), and 21 (35%) detected by 2D-TEE, RT3D-TTE, and 2D-TTE (p <
0.0001). Multiplanar reconstruction enabled RT3D-TEE
differentiate
dominant
Figure 5. to
3D-TEE
and anatomic surgical
picture showing 3 middle scallops of posterior leaflet (
Figuredisplacement)
6. 3D-TEE. (A,C)and
Imaging
compared(2to to
surgical
findings
(B,D)
2 patients
with
different
anatomyinof middle scallop (P2) of posterior leaflet.
scallop,inP3
! medial
scallop.
(>5-mm
secondary
<5-mm
displacement)
prolapsed
segments
Monolobe
P2 clearly
separated
by 2 clefts (arrows)
fromlesions
lateral (P1)
and medial
scallops
posterior leaflet, mirrored by surgical view (B). (C) Bil
agreement
with
surgically
recognized
dominant
(100%),
but(P3)
with
a lowof predictive
Chordae with 2 for
subunits
M1 and M2
owing toInincomplete
indentation
(pseudocleft,
broken arrow)ofconfirmed
by surgical anatomy (D).
valueP2(34%)
secondary
lesions.
addition,
owing to
the identification
clefts and
subclefts (indentations of MV tissue that extended >50% or <50% of the total leaflet
height, respectively), RT3D-TEE accurately characterized the MV anatomy, including that
whichvalue
deviated
from the standard
nomenclature.
In conclusion,
providedbalance
more of functional MV anatomy, targ
to discriminate
dominant
from secondary
lesions. RT3D-TEE
comprehensive
accurate
mapping
of MV prolapse
2D imaging
and RT3D-TTE,
quantitative
Using
these diagnostic
criteria,than
our large
study population,
ingadding
the mitral
regurgitation mechanism and the related s
recognition
of dominant
and secondary
lesions
and MV
© 2011 22
Elsevier
characterized
by a relevant
percentage
of patients
withanatomy
com- details.
gical strategy.
These findings could be of paramount r
Inc. All
rights
reserved.
(Am
J
Cardiol
2011;107:1365–1374)
plex MV disease, found that RT3D-TEE was both more
evance owing to the less-than-optimal results of surgi
accurate and more reproducible than 2D imaging for the
repair, especially in those patients with multisite prolap
23–26
assessment
of
MV
lesions.
According
to
the
per-patient
in 2D-TEE)
the currentand
era.RT3D-TTE
Accurate localization of the valve lesion is crucial when
imaging (2D-TTE and
for MV
Conclusion analysis,
RT3D-TEE
provided incremental
diagnostic
Carpentier’s
nomenclature
describes
planning the surgical
repair strategy
for prolapse-related
functional
anatomy assessment,
using
as a standard
the 2 clefts in the p
1–3
mitral
regurgitation.
The
recent
availability
of
the
Mitrasurgical
findings
in posterior
a group
of
patients
with
value, (B,D)
especially
for the
of complex
multisegterior leaflet.
leaflets;
wasprolapse-related
seen by Quill et al27 to be true on
Figure 6. 3D-TEE. (A,C) Imaging compared to surgical findings
in 2 patients
withassessment
different anatomy
of middle
scallop
(P2) of
(A) this
Figure 5. 3D-TEE and anatomic surgical picture showing 3 middle scallops of posterior leaflet (P2a, P2b, P2c) split by complete clefts (arrows). P1 !
th
Clip
system
imposes
aand
detailed
depiction
of
mitral
regurgitation
undergoing
valve
repair.
ment
disease
involving
or
compared
in(B).
66%
ofpBilobe
the
examined
Although the standard
cle
P2 (A,C)
clearlyImaging
separated
by
2 clefts
lateral
(P1)
medial
(P3)
scallops
of
posterior
leaflet,
mirrored
(C)leaflet.
OBADIA ean-­‐François
further
from
findings
PMVR SMV
ummit scallop,
Barcelona -­‐different
1one
9-­‐20
anatomy
both
June leaflets
2015
by
surgical
to
(P2)
Download this resenta0on on hearts.
« chircardio-­‐lyon.org » Figure Monolobe
6. J3D-TEE.
compared
to(arrows)
surgical
(B,D)
in
2–
patients
with
of mitral
middle
scallop
ofview
posterior
(A)
P3
!
medial
scallop.
[16]. There are diff
summarized by Mu
fied them on the b
nous cords referred
free edge of mitral
can be identified fo
the posterior leaflet
lops) are called cle
free edge are called
Figure 2 (A) The aortic leaflet of the mitral valve is in fibrous continuity withcoapting
the leafletssurfaces
of the aortm
the leaflet. The undersurface of the rough zone in this mitral leaflet has many cordal
attachments.
T
on the
anterior (B)
leafl
basal zone (bracket) which inserts into the annulus at the left atrioventricular junction (arrow).
these arise from th
be the strongest. Fin
i5
tricular wall and are
the so-called basal
sidered to represen
ered as belonging
ventricular aspects
The papillary m
Fig. 5. The rough zone (RZ) is the border area where tendinous cords attach. The larger
sate for the geom
remaining portion of the leaflet is called smooth zone (SZ).
[15]. On the contrary the posterior leaflet is the key structure in the
closure of the valve. Its structure is similar to a skirt with pleats.
When the posterior annulus contracts, first the scallops coapt together, then the leaflet, moving towards the anterior one, coordinates the
History Ring Anatomy of the MV
Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
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PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Secondary Chordae Primary Chordae Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
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PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History of the
body of the leaflets [6 – 8]. All There
chordae
were nowere
differences inthe
mitral left
orifice atri
diam
tion. Data were compared using a t test for paired
between
measurements
with
a
Hegar
dilator
or
mea
observations,
the level
of significance
set at
p " 0.05
identified
by with
their
insertion
into
the
anterior leaflet (A1
through the
ing the mitral perimeter in the open heart.
for statistical comparison within a species. Interspecies
and A2)
and
posterior
mitral
leaflet
(P1,
PM1,
PM2,
and
diameters
we
The basal
chordae
were easily
identified by their
comparisons of basal chorda number were done using
angular-shaped insertion into the ventricular aspe
P2). The two constant and thick anterior (AS)
and The
postewas
then
sec
the leaflets.
total number
of basal
chordae
18.81and
! 3.54 AS2
in the human,
4.21 in the
rior (PS) strut chordae were identified as AS1
for 24.6 !sinus
ofporcine,
Va
19.4 ! 2.98 in the ovine valves. A statistically signifi
the anterior and PS1 and PS2 for the posterior.
The
other
ventricular
difference
was found
between the
number of basalfr
c
Ring Fig 4. Left atrial view of the mitral valve. The continuous line represents basal chorda insertions into leaflets. Large stars represent the
insertion of the anterior strut chordae. Smaller stars represent the
insertion of the posterior strut chordae. Dots correspond to insertions
of basal chordae. (AS1 and AS2 # anterior strut chordae; AB1 and
AB2 # lateral anterior basal chordae; PS1 and PS2 # posterior strut
chordae; PMB1 and PMB2 # lateral posterior basal chordae.)
Leaflets dae in the human and porcine valves but not in
human and ovine valves (ANOVA, Bonferroni corre
significance level, p # 0.0167).
The leaflet insertion of the basal chordae intoF
undersurface of the anterior leaflet was at the junctio
a
the smooth and rough zones (Fig 2). The anterior le
smooth zone height varied considerably between bi
vidual valves: mean 10.78 ! 3.20 mm in porcine (ranA
to 15.88 mm); 6.46 ! 1.66 mm in ovine (range, 5 to
mm), and 10.22 mm ! 1.71 in humans (range, 6.77 tob1
mm). The leaflet insertion of the basal chordae into
t
posterior leaflet and commissural areas was always c
d
to the annulus in all three species (Fig 3). In fact, ex
for the anterior leaflet, all basal chordae were inse
t
around the annulus (Fig 4).
The AS and PS chordae were easily identified s
in
three species as the most medial basal chordae and c
Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » length and
length)/end-diastolic
length-enà-systolic
Wc computeddPidt
valucs.1z
preisedaspe;centageof ba.seline
ed l0
ôf the l.fr ventricular pressure and used its marimum ancl
312.1
vdae't
timc accordminimumvaluesas end-diastolicand end-systolic
, toOK;
ing to the ref'erencetechnique.l:
cold'
Threeeoicardialelectrodesfbr ECG recordingwere positionecl.Thisc ooeratiotts lasted -20 minutes in Langendorll
l, the:
mocle,
a 10-J shockto obtain defibrillation.
a phasercquiring
Subvalvular
Apparatus
J aMitral
nd'
followeclby an equilibration period until a stable. regular
'
;. The
-20 minutes in rvorking
Different
Functions
of Primary
and Secondary
rhythm
Chordae
then another
rvasobtainecl,
ne 20
All of the
modebeforethe variousrecordingsrvere initiated.
3125
Apparatus
Mitral
JeanF. Obadia.MD. PhD; CendrineCasali,MSc:
Circula\on 1997;96:3121-­‐312 et al MD:
Obadia
Jean
F. Chassignolle.
MarcSubvalvular
Janier.MD
parâmeters
(left atrial prcssure,left ventricularpressure.antl
in the
B
Ilackground Thc aint ol this stucly was to compare the
A (Control)'
in group
Groups
significantly
lower than
in the control
Results
(P:,006).
In
Hemodynamic
lunction of the primarvchordac
. This
attachcdto the free eclgewith
C,
sectioning
the
of
secondarv
chordae
(Secondary
left
a
competent
C
and
mit
Sectioned),
(Primary
Chordae
that of the seconclarychorclae attached to the t,entricular
valve
rvith good coaptation
)
of :the?anterior
G . n , * i l î l Chordae
B (N
î - i - Ctosether
. o r r nSectioned)
iand ( i r o r r p C ( N = ? )
of .
ion
surfaceol the anteriormitral
leaflct.
rior leaflets shown by video monitoring. However. aortiè
Methodsand Results An isolated.;
working pig heart model
waslower than in the controlgroup (P:.007). an<Iultr
'fhree
GrouP C
Group B
A
Group (P=.009).
was used.
groups of 7lrebs'
heiirts werc colrpared: Group A
crometryevidencedimpairedfunction
I
History Ring Leaflets rhp
rectlY
) The
'geia'
lv:rs the control groLrpwith intact leaflcts.In group B, thc
primarvchordaeof the antcrior leaflelwere sectionedand the
secondaruchordae werc left intact before assemblvof the
working heart model. In group Cl,the secondarychordac were
sectionedand the primarychordaeleft intact.In groupIl, atrial
and ventricularprcssurecl'iclenceddramaticrnitral regurgitation. Vidco monitoringshowerlsignificirntprolapseof the free
edgc of the anterior lcaflet. Acute mitral regurgitationaccounted lbr the decreasein aortic flow rate to 30 ml/min.
b Ya '
differ'
red ttt
here are sevcralarguments
in thelin favor of preservin-u,
insofâras possible,the internal structureof the
left ventricleduring
mitral1'
valvesurgery.L-3
Such
thout
argumentsfavor mitral repair rather than replacement
ârdial]:
whcneverpossible.a
In prosthetic
valvereplacèment,the
Conclusions This study suggeststhat the primary
3 0 : 4and
5
1100+135
m i the
n
o w ,m Uof
A
o r t i cf lchordae
ondary
mitral subvalvular appararus
SF,prinrrn chordaeof the ànteriorle
dillerentfunctions.1'he
Sonomicrometry,
3*6
appeared
21
3
to be more involved
in+mitral
valve2 compe
%
whereasthe secondarychordae appearedto be more int
ventricular
LeTt
in
left ventricular gcometry and function. (Cl
86+8/16+3
101/13
pressure,mm Hg
1997;96:3121-3128.)
Keyatrial
llords r mitral valve r ventricles .
Left
60a8/16*3
25x3/15*2
contraction
pressure,mm Hg
8 5 0 - 10 4
17*3
J
90+8/14*3
30+6/17*3
aremeanlSD'
Values
fraction.
shortening
SFindicates
ventilation, 8 L: tidal volume, 450 mL; 50% oxygen).
sternotomy was then performed, and the heart was ha
by the usual method, after aortic
clamping
and infusion
of
for 10 mincontinuously
recorded
werc
ultrasonomicrometry)
mL of crvstalloid solution (St Thomas No. 2) into the
for PC. Aortic and coronaryflow
software
Lab-Vierv
with
utesf'he
root.
excised
hearts were
placed into cardioplegicfluid
in the
4'C.
groups
Three
directly
of 7 hearts
u'ere lormed
measurccl
postcrior leaflet is now generailyprcservedby the maby aortic
randomiand pulmonary lines
wcrc
rates
(Fig 2).
jority of surgeons,..{'
10
minutes Afïer the recordthose
and there is increasingemphasison
during
three occasions
on
In group A (n:7), the control group, the left atrium
the importanceof preservingthe antericlrnitral valve in
transmitterwas insertedthrougha left atrial
vicleo
ing phase,
'fhe
opened.
but theamitral
leafletsrvereleft intact. The hearts
severaltechniques.T.s dual role of left vcntricular
i
of the left ventricle in
the20apcx
located
a bursa
presened
in cold
cardioplegic
bu"ria ancl
iluid toattime
minutes.
competenceand functionof the mitral valveis therefore
In group B (n:7),
and ventricularsurfaces
after
the left
ofatrium
thc atrial
was opened,
display
Direct
succession.
acknowledged,though globally, on the basis of arguprimary chordac of the anterior leal]et (chordae attached
vicieorecording'
with
ments regardinglcfi ventricularfunction and postoperr,vasthus possible
valve
mitralrvere
the edge)
of free
the
sectioned ar-rdthe secondary
ative
course
after
valve
replacement.')
the aortic root' modiby-Ihis
Conclusion attached
wereside)
the
(chordae
Because
attached
to hearts
the vcntricular
left intact.
This researchaimed to investigateantl cleterminethe
and
l0fications
could
to l-5 minutes.
The
hcarts were geometn
thcn presen'ed
in be suspected,
ventricular
of the
bubble
pig heartenabling
model"-1
workingmechanisms
thcrndicates
mitral valve
,:t,
to play
i ' r r r d i o p l r ' gfi ler r i dt o t i r n e2 { tn r i n u r c son
Fro1. lsolatedanatomic
.
normal
the
to
mimic
pad
a
wet
restedthis presenta0on on « chircardio-­‐lyon.org » pump;-­‐ 4'
hearts
the
dual
P, roller
comparc
CML;
the
clifferent
functioni
oxygenator
this 3,
role and to
Cobe
PMVR Summit – Barcelona 1of
9-­‐20th June 015 C werc
also
after
Download group
In 2
(n:7),
.:lOBADIA Jean-­‐François
2, postcfrarge;
the left atrium was opened,
,
Chordae trunl,
in the:
l. tb€.:
ithout
l'n z. Experimentaldesign in group A (control),grouP B
(Primary
chordaesectioned),and group C (secondarychordae
sectioned).
minimum
valuesas end-diastolic
ing to the ref'erence
n5
ing
technique.l:
, toOK
;
totechnique.l:
ref'erence
the
m
the 10
; 8 0
'
ml/min ôver
ôver
cold
ml/min
posiing
technique.l:
were
to
ref'erence
the
recording
fbr
ECG
posiwere
Threeeoicardial
electrodes
Three
cold' eoicardialelectrodesfbr ECG recording
ml
8 6 0
ra
Heart
mode.
posiworking
were
recording
mode
fbr
ECG
working
-20
Three
electrodes
eoicardial
Langendorll
in
-20
minutes
tionecl.
lasted
Langendorll
in
Thisc
minutes
ooeratiotts
tionecl.
lasted
Thisc
ooeratiotts
wo
312.1
-20 minutes
40
Langendorll
in these
10 minutes
l, the:
tionecl.
lasted
over
Thisc
ooeratiotts
these 10
over
defibrillation.
obtain
to
shock
defibrillation.
mocle,
10-J
obtain
a
to
shock
a phasercquiring
mocle,
10-J
a
phase
rcquiring
a
the:
l,
ovth
defibrillation.
to obtain
shock
mocle,
10-J
auntil
J a n dby
' anfollowecl
rcquiring
a phase
in
thoseparam
regular
in
stable.
difference
regular
a
until
stable.
difference
followecl
period
a
period
equilibration
equilibration
by
an
Jand'
'
difv
a stable. regular
until
followeclby
period in
equilibration
;. The
-20ananother
-20
in rvorking
rvorking
minutes
of the
rate)heart
minutes
rhythm
rat
another
heart
rhythm
' rvas
thenobtainecl,
and
then
and
rvasobtainecl,
The
;.
-20
1, 1997
November
in rvorking
Vol 96, No 9 then
Circulation
3126 rhythm
an
20
rvas
obtainecl,
nebefore
of the grouPs.
of
the All minutes
Allanother
rvere
initiated.
rvere
initiated.
mode
mode
recordings
recordings
various
the various
the
Time (sec)three grouPs
three
20before
ne
of
the
rvere initiated.
modebefore
recordings
various
the
thr
antl - L AAll
antlpressure.
pressure.
parâmeters
left
- Sventricular
ono
---.. LVP
left ventricular
(left
prcssure,
(leftparâmeters
atrial
atrial prcssure,
P
A
-ThJresults
S oobtained
no
.
.
.
.
.
L
V P pressure.
ThJresults
antl
parâmeters
ventricular
left
(left
prcssure,
B
Mitral
atrial
Subvalvular
Apparatus
in the
160
T
in the
in lthe
Table,
given
given in the
6and
160
. ThisDifferent Functions1 4 0
giv
of
Primary
and SecondaryChordae
. This
(irorrp (N = ?)
with
iecorcled
Lab-View
with
1,1
. o (r N
r n: ? )
G
. n ,of
* .i l î l î - i - C . o r rGn. n , * i l î l î - i - CB
i B( i(rNo:r r p? )C ( Ni = ? )( N : ? ) C140 iecorcled
ion
=
(
i
r
o
r
r
p
(
N
?
)
iec
C
'120
G
.
n
,
*
B
ilîlî-i-C.orrn
i
12
.;
ionof .
gr
three
F
the
in
groups
three
t
2
the
t20
lrebs'
JeanF. Obadia.MD. PhD;
Circula\on 1
997;96:3121-­‐312 .; CendrineCasali,MSc: Jean F. Chassignolle.MD: Marc Janier.MD
th
lrebs'
= 1oo
a pr
ventricular
sh
cold'
6
l, the:
Jand'
;. The'
ne 20
History in the
. This
ionof .
.;
lrebs'
Ring :
4
J J J
{^
q
5
r o i
ventricularpressures
ve
viâe
anci
tion,
significantly
lower than in the controlgroup (P:,006).
In
monitor
viâeo
U
;
'
anci
tion,
; 8 0
tio
C, sectioningof the secondarvchordae left a competent mit
edg
free
the
valve tosetherrvith good coaptationof the anterior
a
the
and free edge of
6 !
the
P 6 0
9 th
rior leaflets shown by video monitoring. However. aortiè
a
'
40
band
Y Results An isolated a
Acur
mictdle).
Methods
pig heart model
waslower than in the controlgroup (P:.007).
mitral
4
'
40an<Iultr
b Ya '
Acute
mictdle).
'fhree
b Yworking
m
was used.
groups of 7 heiirts werc colrpared: Group A
crometryevidencedimpairedfunction (P=.009).
differ'
a
in
decrease
lv:rs
the control groLrpwith intact
leaflcts.In group B, thc
differ'
llolv
Conclusions This study suggeststhat the primary
aortic
in
differ'
decrease
and
de
primarvchordae
were sectionedand the
ondary chordae of the mitral subvalvular appararus
red tttof the antcrior leaflel
with 1100ml/
ttt
red
secondaruchordae werc left red
intactttt
before assemblvof the
dillerentfunctions.1'heprinrrn chordaeof the ànterior
with
wi
le 1100ml/min in th
Leaflets thel
inVolmodel.
working heart
In group Cl,the secondarychordac were
appeared to be more involved in mitral valve compe
ultraso
ever,
thel Circulation
1,
1997
No
9
November
thel
96,
(sec)
in3126
Time
in left intact.In groupIl, atrial
sectionedand the primarychordae
ultrasonomicrom
whereasthe secondarychordae appearedto be more
ever,
ev
int
Time (sec)
1' cl'iclenced
thoutprcssure
and ventricular
dramatic
rnitral regurgitamai
was
in
left
ventricular
gcometry
1'
(Cl
1'
tion
and
function.
thout
-LAP
thout
S
o
n
o
.
.
.
.
.
L
V
P
by
- S o n osignificirnt
- - - . . L V P showerl
tion. Vidco
monitoring
was
tio
prolapse
B of the free
1997;96:3121-3128.)
- Ltion
AP
-Sono
. . . - - L Vmaintained
ârdial]:
A
P
lcaflet. Acute
by
the
ârdial]:
mitral regurgitationacducecl
ârdial]:1 6 0 edgc of the anterior
Key llords r mitral valve r ventricles .
l6
60
,
du
counted lbr
duceclby the mitral reg
the decrease
in aortic flow rate to 301 ml/min.
trunl
160
contraction
trunl,
of
trunl, 1 4 0
sectioning
1,1
140
B
se
in the:
A (control),
of the
z.
sectioning
140grouP
design in group grouP
l'n
the:Experimental
grouP
B seco
(control),
in
group
A
z.
in
B
com
Experimental
design
(control),
in the:'120
group
A
remained
z.
in
Experimental
design
l'n
(Primary
here
are
sevcralargumentsin 1favor
of preservin-u,
ventilation,
L: tidal volume,
2
chordae
l'n l. tb€.:
oxygen).
C (secondary
t 2 450 mL; 50%
and8 group
t20 sectioned),
re
a
competent,
(Primary
120C (secondary
remainedchordae
tb€.:chordae
group
(Primary
andand
insofârchordae
as possible,
l.
the
internal
sternotomy
was then performed,
chordae
sectioned),
(secondary
chordae
structure
of the
post
group
C
and
l. tb€.:
sectioned).
anci
sectioned),
a the heart was ha
rior
=
1
o
o
ithout
r oclamping
i
left
ventricleduring mitral valvesurgery.L-3
E sectioned).
by the usual method, after aortic
l o o Such
Chordae E and
1,0r rio
too infusion
sectioned).
riorof anciposteriorleafl
ithout
mL of crvstalloid solution (St Thomas No. 2) into the
argumentsfavor mitral repair
ithout
rather than replacement
rectlY
rectlY
) The
Ilackground
8 0
Thc aint ol this stucly was to ;compare
the
) attachcd
lunction of the primarvchordac
The
to the free eclgewith
8 6 0
that of 'geia'
the seconclarychorclae attached to the
t,entricular
'geia'
surfaceol the anteriormitral leaflct.
rectlY
) The
'geia'
E loo
6
:
4
1 )
{^
; 8 0
q
5
U ; ' into
root. f'he excisedhearts were placed
whcneverpossible.a
U'U 5'
; 8 0
In prostheticvalvereplacèment,
fluid
: 8cardioplegic
0
the
æ
4'C. Three groups of 7 hearts u'ere lormed by randomi
postcrior leaflet is now generailyprcserved
by the ma6
:
6
!
0'6 i
p 6 0
(Fig 2).
P 6 0
jority of surgeons,..{'
and there is increasingemphasis
9
on
In group A (n:7), the control group, the left atrium
4
the importanceof preservingthe antericlr
nitral 4valve
in
4
0
0,4
40The hearts
'fhe
opened.but the mitral leafletsrvereleft intact.
severaltechniques.T.s dual role of left vcntricular
presened
in
cold
cardioplegic
iluid to time 20 minutes.
competenceand functionof the mitral valveis therefore
nt
20
In group B (n:7), after the left atrium was opened,
acknowledged,though globally, on the basis of arguprimary chordac of the anterior leal]et (chordae attached
0,0
0
ments regardinglcfi ventricularfunction and postoperthe free edge) rvere sectioned ar-rdthe secondary
0
1-Ihis 2
3
4
5
6
1
ative courseafter
valve
replacement.')
Time (sec)
(chordae attachedto the vcntricular side) left intact.
Time (sec)
This researchaimed to investigateantl cleterminethe
Time (Sec.)
l0 to l-5 minutes. The hcarts were thcn presen'edin
anatomic
-LAP
enabling
- S o n o thc mitral valve to play
. . . . . L V P mechanisms
i ' r r r.d. .i o- p- l r ' gfi ler r i-dSt o
c s .3. Tracings
parameters.
-LAP
o nt oi r n e2 { tn r i n u rFro
Noteexistenc
of hemodynamic
clifferent
functioni
this dual role and to
comparc
PMVR the
Summit – Barcelona -­‐ 1of
9-­‐20th June 015L V PC (n:7),
after
Download this presenta0on group
In 2
the left atrium
was opened,on « chircardio-­‐lyon.org » I
8 6 0
40
Conclusion B
OBADIA Jean-­‐François
History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ant. Leaf. / Double Part è Double Func/on Ring Leaflets Secondary Chordae Primary Chordae LV FuncGon ConGnence Load Bearing Basal Chordae + Basal Leaflet Aligning Chordae Marginal Chordae + Marginal Leaflet Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets were mounteded and
onto
the four individual chordae,
left
atriumdrainage
in the
placed viaas
the right atrium
to accomplish
compared to the human mitral valve, and has
from
the
atrium
and
vena
cava
inferior.
After
aortic
also been
found
to bechorda
the most suitable
animal
model
shown in Figure
2.
The
to
be
examined
was
acoustic
contact.
crossclamping,
the
heart
was
stopped
by
administra(11). In postulating that secondary chordae are the
tion of cold crystalline cardioplegic solution (St.
principal
force mediators
in the valvular-ventricular
subsequently interaction,
severed
between
the
fixing
points
to solutionwhere
Thomas'
Hospital,
number 1)ainlong-axis
the aortic
the aim of the present in-vivo study was to
tension in
the secondary
primary mitral
tricle was obtaine
ensure that allcompare
chordal
force
wasandtransmitted
through
chordae tendineae.
the c-ring. The c-ring was made of brass, 6 mm in
cineloop images
Differentialand
Tension
Secondary
and Primary
diameter
0.8between
mm thick.
A miniature
strain gauge
plane were down
Mitral Chordae in an Acute
In-Vivo Porcine
Madel Inc., Raleigh,
(EA-06-031DE-350;
Measurement
Group,
Mads Lomholt, Sten Lyager Nielsen, 50fen Berndt Hansen, Niels Trolle Andersen, J. Michael
NC,
USA) was mounted on bath the outer ""and inner
Study protocol
Hasenkam
Department of Cardiothoracic and Vascular Surgery and Institute of Experimental Clinical Research, Skejby Sygehus,
JHeart Valve Dis
Measurements
ring
surfaces
in 2a002;11:337-­‐345 Wheatstone half-bridge.
Journal of and
HDenmark
eart coupled
Valve Disease University
Hospital, Aarhus,
Aarhus The May2002
ters were perfor
A strain indicator (2021; Measurement Group,
Inc.)
T Basal = 3 x T Marginal Figure 2: Right: Miniaturestances:
chordal
force transducers,
A
tendineae
tension
was
recorded
online
in
the
openBackground and aim of the study:Figure
Chordae1:tendineae
Schematic and photographie representation of the
which
are
mounted
on
the
surgically
exposed chordae
3.0
may be instrumental for valvular-ventricular interacchest condition with spontaneous circulation in
l.
Baseline
condit
mitral
valve.
The
left
ventricle
has
been
opened
and
the
tendineae.
Units
shown
are
cm.
Left:
Miniature force
CTT,
LVP
and
ECG
trac
lng
three different hemodynamic conditions: baseline
tion, i.e. the reciprocal exchange of force between the
•
leaflet
has
been
detached
from
the
annulus.
Primary
transducers
implanted
on
the
chordae.
One
transducer
is
left ventricular myocardium and the mitral apparawith no intervention; partial aortic occlusion; and
•
intervention.
chordae
insert
in
the
leading
edge,
and
secondary
chordae
implanted
on
a
secondary
chorda
(foreground),
and
one
on
!
2.0
tus. Chordae tendineae are divided into primary
during dobutamine infusion.
the leaflet
belly.
a primary chorda (background).
100.0
1.0edge chordae and secondary belly chordae, intoResults:
leading
Systolic
tension in secondary chordae
under
1::
2. Partial aortic o
and differences in thickness and distribution may
baseline conditions was significantly higher than in u
•
1.0
primary chordae (0.7 N versus 0.2 N, respectively).
reflect different fonctions of the two types. Primary
0.8may be fondamental for leading edge conchordae
No significant impact on this distribution80.0
by changtricular pressure (
trol and for correct leaflet coaptation, while seconding the hemodynamic condition could be identified.
on
ary chordae
Conclusion: Chordal tension is distributed
towards
3. During
0.8 may act as the main mediators of
60.0
- LVP
PS
PS dobuta
AS
AP
the secondary chordae, with a tension more than
valvular-ventricular interaction.
was postulated
three-fold that in the primary counterpart. The magthat tension in secondary chordae of the anterior
ECXl
arterial pressure o
nitude of chordal tension seems to be determined
40.0 l
leaflet
is greater than in the primary chordae. The
!:
0.4
&
AP
primarily by ventricular pressure. This finding supstudy aim was to investigate the distribution of
!. - PP
The
aorta was p
B
ports the hypothesis that secondary chordae are more
chordae tendineae tension in the porcine mitral
li in0.2vivo.
20.0
important mediators of the valvular-ventricular
valve
- 3.0
PS
interaction than are primary chordae.
Methods: During extracorporeal bypass, miniature
pr
• tricular-aortic
•
chordal force transducers were implanted on four
AS
•
0.0
0.0
The Journal of Heart Valve Disease 2002;11:337-345
chordae in 23 Danish Landrace pigs. Chordae
• rate was
infusion
z 2.0
....i
time (dP /dt) .
moted a reduced late mortality (8). This beneficial 6 1.0
Since the first successful implantation of a mitral
Vol. 11. No. 3
•
It
Chordae •
effect has been assigned to preservation of the sovalve prosthesis during the early 1960s (1), replacecalled valvular-ventricular interaction (9). This interment of this valve has gained worldwide acceptance.
a complex
0.00
0.25 the
0.50enhanced
0.75 use1.00
1.25 action
1.50 is1.75
2.00mechanism
2.25 which
2.50 serves a dual
During the
past decade,
of valve
0.0
PP
fonction: (i) It enables a long-axis contraction of the
AP
PS
repair at the expense of replacement has been encourAS
Timo [si
left ventricular myocardium by approximating the
aged by numerous experimental demonstrations that
Conclusion apex of the heart to the annular plane; and (ii) it assists
the mitral subvalvular apparatus, that is, the chordae
valve closure, prevents prolapse, and may also facilitendineae and papillary muscles, is of paramount
mitral valve
opening.
importance
(2- – Btate
th June 2015
OBADIA Jean-­‐François
for left ventricular pump
performance
PMVR Summit arcelona -­‐ 19-­‐20
Download this presenta0on on « chircardio-­‐lyon.org » Data analysis
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OBADIA Jean-­‐François PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » 33333333333333333333333333333333333333333333333333333333333333333
8)(4%$7 0+'#4 (%01+./ 4% ),,%: ) $/(+-$%()4+.'6 7,+.'C,+I/6 J0%$C
ingue deux zones d’obstruction dans la CMH (Figure 16-3) :
struction médioventriculaire liée à l’hypertrophie pariéaffrontement des piliers hypertrophiés ou à l’existence
s anormaux. Cette obstruction médioventriculaire peut
e VG en deux cavités avec exclusion de la pointe (aspect
History et
n
c-
pathie hypertrophique obstructive. L’hypotrophie av
de courbure septale dévie le flux de vidange ventriculaire
va entraîner la valve mitrale dans la voie d’éjection. Le ph
Venturi attire encore la valve mitrale antérieure vers la
(SAM). La perte de contact entre les feuillets antérieur et p
responsable de l’IM.
ASPECTS CLINIQUES
MR in HCM: mulGple mechanism Ring eà
csa
té
n
l, Leaflets de
cfs
ade
a
b
de
Chordae cie
it
Figure 16-1 Représentation schématique du mécanisme de l’ins-
1) Pulling Mechanism è Venturi effect ):
éce
ut
suffisance mitrale (IM) fonctionnelle au cours de la cardiomyopathie hypertrophique obstructive. L’hypotrophie avec inversion
de courbure septale dévie le flux de 2) vidange
ventriculaire
gauche qui è Direct flow Pushing Mechanism la valve mitrale dans la voie d’éjection. Le phénomène de
Venturi attire encore la valve mitrale antérieure vers la paroi septale
La perte
entre
antérieur
et postérieur
OBADIA (SAM).
Jean-­‐François
de contact
les
Pfeuillets
MVR Summit – Barcelona -­‐ 19-­‐20th Jest
une 2015
Download this presenta0on on « chircardio-­‐lyon.org » Conclusion va entraîner
History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets Chordae Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History 111 pa\ents : 61 % EVEREST exclusion criteria Table1 1 month è 34% grade 3 and 4 726
Mitral valve anatomy prior to MitraClip implantation and at follow-up.
Ring Leaflets Chordae MR grade ≥ 3, (%)
MR etiology, (%)
Functional
Degenerative
Mixed
Jet origin A2–P2, (%)
Jet direction, (%)
Central
Posterolateral
Anterior
Anterolateral
Coaptation length, (mm)
Coaptation depth, (mm)
Flail gap, (mm)
Flail width, (mm)
Length PMVL, (mm)
Length AMVL, (mm)
Annulus diameter 0°
Annulus diameter 120°
MVA<4cm2, coapta\on length < 2 mm, Letters to the Editor
Coapta\on depth > 11 mm, flail gap > 10 mm and flail width ≥ 15mm. All patients baseline
MR grade ≤2 at follow-up
MR grade ≥3 at follow-up
n = 79
n = 47
n = 24
100
100
100
ns
53
38
9
70
62
30
8
74
42
50
8
71
ns
ns
ns
ns
63
19
10
8
3
8
5
13
14
25
35
34
72
17
4
6
3
7
5
13
14
24
35
33
42
25
25
8
3
10
6
15
15
27
35
33
0.02
ns
0.02
ns
ns
0.01
ns
ns
ns
0.049
ns
ns
±1
±3
±3
±4
±4
±5
±5
±6
±1
±3
±2
±2
±4
±5
±5
±6
p-Value
±1
±2
±4
±2
±4
±6
±4
±4
Values are in % or in mean ± SD. p-Value is between MR grade ≤ 2 and ≥3 at follow-up. ns: not significant; PMVL: posterior mitral valve leaflet; AMVL: anterior mitral valve leaflet.
[4] Surder D, Pedrazzini G, Gaemperli O, et al. Predictors for efficacy of percutaneous
Mitral valve anatomy predicts outcome of M
itraClip implanta0on mitral
valve
repair using
the MitraClip system: the results of the MitraSwiss
registry.
Heart12013;99(14):1034–40.
Kirsten Boerlage-­‐van Dijk, Int for
J oa f Cardiol 2014 74 (3) 724-­‐6 [1] Mauri L, Garg P, Massaro JM, et
al. The EVEREST
II Trial: design and
rationale
[5] Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral
randomized study of the evalve mitraclip system compared with mitral valve
Amsterdam regurgitation. N Engl J Med 2011;364(15):1395–406.
surgery for mitral regurgitation. Am Heart J 2010;160(1):23–9.
References
Conclusion [6] Altiok E, Becker M, Hamada S, et al. Real-time 3D TEE allows optimized guidance of
[2] Franzen O, Baldus S, Rudolph V, et al. Acute outcomes of MitraClip therapy for mitral
percutaneous edge-to-edge repair of the mitral valve. JACC Cardiovasc Imaging
regurgitation in high-surgical-risk patients: emphasis on adverse valve morphology
OBADIA Jean-­‐François
dysfunction.
PMVR Summit Barcelona -­‐ 19-­‐20th June 2015 2010;3(11):1196–8.
Download this presenta0on on « chircardio-­‐lyon.org » and severe
left ventricular
Eur
Heart J –
2010;31(11):1373–81.
coapta\on length < 2 mm, flail gap > 10 mm flail width ≥ 15mm. History Ring Leaflets Measurement of the flail gap where flail gap is largest Measurement of the flail width where flail width is largest in a transgastric short axis view (0°). Chordae Measurements of coapta\on length in a 4 chamber view in 0°, Coapta\on length is measured in the view where coapta\on length is shortest Mitral valve anatomy predicts outcome of MitraClip implanta0on Kirsten Boerlage-­‐van Dijk, Int J of Cardiol 2014 174 (3) 724-­‐6 Amsterdam Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » History Ring Leaflets Measurements of anterior and posterior leaflets at maximum length in 120° Cut offè less than 28 mm Measurements of coapta\on depth in a 4 chamber view in 0° where the coapta\on depth is greatest. Cut off è less than 10 mm Chordae Mitral valve anatomy predicts outcome of MitraClip implanta0on Kirsten Boerlage-­‐van Dijk, Int J of Cardiol 2014 174 (3) 724-­‐6 Amsterdam Conclusion OBADIA Jean-­‐François
PMVR Summit – Barcelona -­‐ 19-­‐20th June 2015
Download this presenta0on on « chircardio-­‐lyon.org » Ann Thorac Surg
2007;84:1250 –5
244
History M. Di Mauro et al. / International Journal of Cardiology 163 (2013) 242–248
The aortic leaflet is a compact, semicircular structure, without any
indentation. It is positioned antero-superiorly in the left ventricle.
When viewed from the ventricular aspect, the defining feature of
the aortic leaflet, and the reason for this name, is seen to be its fibrous
continuity with the left and non-coronary leaflets of the aortic valve.
Indeed, unlike the tricuspid valve which is separated by muscle from
its counterpart, the pulmonary valve, the mitral valve is immediately
adjacent to the aortic valve. The insertion of the aortic leaflet, guards
about 35 to 40% of the annular circumference and it is fibrous with
some scarce muscular intrusions. The two leaflets of the mitral
valve, although very different in shape, they share an almost equal
area. It is made largely by a smooth zone, which is devoid by tendinous chords. The layered attachments of the tendinous chords represent the so called rough zone (Fig. 5) [11]. The rough zone is present
in both leaflets and is broadest in the lowest portion of each leaflet,
but tapers toward the periphery of the closure line, the commissures.
It includes the coaptation zone, where the leaflets meet with the posterior leaflet, 4–6 mm deep into the ventricle.
The mural leaflet, normally called posterior, has more variability
than the anterior leaflet. It is narrow and extends two-thirds around
the left atrioventricular junction within the inlet portion of the ventricle. Made mainly by three scallops, there is still debate if it represents a single unit or a whole of independent leaflets. The three
scallops are named, from the anterolateral to the posterolateral commissures, respectively P1, P2 and P3 (Fig. 6). The facing corresponding
portions of the anterior leaflet, for practical reasons, are called A1, A2
and A3, even if in the anterior leaflet no scallop can be identified [13].
Recent anatomical studies, however, showed that the usual pattern “anterior leaflet = no cleft; posterior leaflet = two clefts” is not
the commonest one [12]. A deviant cleft in the anterior leaflet is present in 26.3% of the cases, whereas in the posterior leaflet 2 clefts are
present only in 38.9% of the cases, no cleft at all in 2.8%, 1 cleft in
33.3%, 3 clefts in 13.9% or 4 clefts in 11.1%. In 36.9% of the cases 1 deviant cleft was present in mid A2, mid P2 or in both.
The mitral valvar leaflets close along a solitary zone of apposition;
the extremities of this zone do not reach the annulus. The portions
beyond the end of the zone of apposition are called commissures;
they are commonly known as antero-lateral and postero-medial commissures, based on a description of isolated organ in its own. The
antero-lateral commissure position is superior, posterior, lateral,
while the postero-medial is inferior, anterior, septal, if considering
heart in the body [12,14].
The aortic leaflet is a monolithic structure, which participates passively in the mechanism of closure of the valve. In fact its insertion includes all the fibrous tissue of the mitral annulus, which then does not
participate to the change of the mitral area during the cardiac cycle
[15]. On the contrary the posterior leaflet is the key structure in the
closure of the valve. Its structure is th
similar to a skirt with pleats.
CONCLUSION Leaflets Chordae Conclusion OBADIA Jean-­‐François
Fig 1. Terminology superimposed on an atrial view of the mitral valve.
(T1 ! left trigone; T2 ! right trigone; C1 ! anterolateral commissure;
C2 ! posteromedial commissure; A1 and A2 ! anterior leaflet; P1 and
P2 ! posterior leaflet lateral scallops; PM1 and PM2 ! anterolateral
and posteromedial segments of the posterior leaflet mid-scallop; M1 !
anterolateral papillary muscle; M2 ! posteromedial papillary muscle.)
The Ring is not a ring Aor\c and Mural leaflet Marginal and Basal Chords More Complex than Aor\c è TMVR is not TAVI Ring MITRAL VA
PMVR Summit – Barcelona -­‐ 19-­‐20 June 2015
anterior mitral leaflet and chordae supported by the
anterior papillary muscle (called “M1”) were identified as
A1, the commissure as C1, and the anterolateral scallop
of the posterior leaflet as P1.
The other half of the anterior leaflet, commissure, and
posteromedial scallop supported by the posterior papillary muscle (called “M2”) were identified as A2, C2, and
P2. Because it is supported by chordae from both papillary muscles (M1 and M2), the posterior middle scallop
(PM), was divided into PM1 and PM2. The two trigones
were identified as T1 for the left and T2 for the right.
Similar with previously published classifications, the
mitral chordae were divided into marginal (first order)
when inserted into the leaflet’s free edge and basal
(second order) when inserted into the ventricular aspect
of the body of the leaflets [6 – 8]. All chordae were
identified by their insertion into the anterior leaflet (A1
and A2) and posterior mitral leaflet (P1, PM1, PM2, and
P2). The two constant and thick anterior (AS) and posterior (PS) strut chordae were identified as AS1 and AS2 for
the anterior and PS1 and PS2 for the posterior. The other
Fig 3. A ventricular view of the poster
posterior strut chordae. (PS1 ! posteri
anterolateral papillary muscle; PS2 !
from posteromedial papillary muscle.)
basal chordae located lateral
termed AB1 and AB2 for the
PMB2 for the middle scallop of
and Fig 3). For the purpose
marginal) basal chordae were d
other type of chordae arising
labeled “mixed” when the cho
marginal branches.
Measurements
Before examination of each hea
nary artery were resected 1 cm
sure, and each heart was weigh
of mitral regurgitation, each val
the left atrium while saline
through the aorta. The aortic a
diameters were measured with
was then sectioned vertically th
sinus of Valsalva, interventric
ventricular free wall to allow a
Fig 2. A diagram and ph
aspect of the anterior mi
basal chordae. (Tl ! left
AB1 ! anterolateral bas
basal chorda; AMC ! ao
terolateral strut chorda; A
Fig. 6. (A) The mural leaflets is made mainly by three scallops, named, from the anteda; M1 ! anterolateral p
rolateral to posteromedial P1, P2 and P3. (B) The three posterior scallops, the anterolatteromedial papillary mus
eral (ALc) and posteromedial (PMc) commissures.
smooth zone.)
valve closure process. This mechanism determines the complete closure (coaptation) and correct apposition (symmetrical overlap) of
both leaflets that are essential in preventing regurgitation.
1.3. The subvalvular apparatus
Since Leonardo da Vinci (1513), researchers have understood that
the competence of the valve cannot be afforded by leaflets without
the support of subvalvular apparatus. In the normal valve, groups of
cords sprout from both papillary muscles, forking, and support the
leading edges of both leaflets. The tendinous cords of the mitral
valve are attached to two groups of papillary muscles or directly to
the posterior muscular wall for the tensor apparatus of the valve
[16]. There are different classifications of mitral tendinous cords as
summarized by Muresian [1]. In 1970, Lam and coworkers [17] classi-
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