Circulation, Vol 75, 756-767, Copyright © 1987 by American Heart Association
RA Levine, MO Triulzi, P Harrigan and AE Weyman
The geometric or anatomic diagnosis of mitral valve prolapse, as opposed to
the pathologic diagnosis of myxomatous valve disease, is based on the
relationship of the mitral leaflets to the surrounding anulus. Current
echocardiographic criteria for this diagnosis include leaflet displacement
above the annular hinge points in any two- dimensional view; implicit in
this equivalent use of intersecting views is the assumption that the mitral
anulus is a euclidean plane. Prolapse by these criteria is found in a
surprisingly large proportion of the general population. In most of these
individuals, however, prolapse is present in the apical four-chamber view
and absent in roughly orthogonal long-axis views of the left ventricle.
This frequently observed discrepancy between leaflet-annular relationships
in intersecting views suggests an underlying geometric property of the
mitral apparatus that would produce the appearance of prolapse in one view
without actual leaflet distortion. To address this possibility, a model of
the mitral valve and anulus was constructed. When the model anulus was
given a nonplanar, saddle-shaped configuration, the clinical observations
were reproduced: the leaflets appeared to lie above the low points of the
anulus in one plane, and below its high points in a perpendicular plane.
Therefore, the appearance of mitral valve prolapse can occur without actual
leaflet displacement above the most superior points of the mitral anulus if
the anulus is nonplanar. To determine whether this pattern is reflected in
the human mitral anulus, two- dimensional echocardiographic views of the
mitral apparatus were obtained by rotation about the cardiac apex in 20
patients without evident annular or rheumatic valvular disease. In all
cases the mitral anulus, as reconstructed from these views, had a nonplanar
systolic configuration, with high points located anteriorly and
posteriorly. This is consistent with the findings of other groups in
animals, and would favor the appearance of prolapse in the four-chamber
view and its absence in long-axis views that are oriented
anteroposteriorly. This model can therefore explain the frequently observed
discrepancy between leaflet-annular relationships in roughly orthogonal
views. It challenges the assumption that the mitral anulus is planar as
well as the diagnosis of prolapse in many otherwise normal individuals
based on that assumption.
ARTICLES
The relationship of mitral annular shape to the diagnosis of mitral valve prolapse
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