Imaging & pathology of the mitral valve

Madalina Garbi MD MA FRCP King’s College Hospital NHS Foundation Trust

MV disease prognosis & management

↓↑ valve morphology

& LV

MITRAL STENOSIS

Imaging & pathology of the mitral valve

MITRAL STENOSIS Rheumatic

commissural fusion, leaflets thickening, chords thickening & fusion => funnel shape

MITRAL STENOSIS

Calcific no commissural fusion => smile shaped orifice

thin leaflet tips / calcified leaflet base

MAC = Mitral Annular Calcification “Calcium bar”

protrusion of calcium chunks apparently restricting the mitral valve orifice

Calcium bar

Kings College Hospital

MITRAL REGURGITATION

Imaging & pathology of the mitral valve

ESC / EACTS Valve disease management guidelines 2012

The role of the imaging cardiologist

→ LV serial assessment

→ Select cases for the “mitral surgeon” Barlow valves Young patients Asymptomatic Anterior leaflet / bi-leaflet prolapse D. Adams et al. Eur Heart J 2010

→ Characterise disease Experience

Mitral valve quantification

S. Chandra et al. (R. Lang) Circ Cardiovasc Imaging 2011

Barlow valve / ventricle echocardiography - extensive leaflets prolapse / atrialisation (insertion point pseudo-displaced within LA) - prolapsing volume exclusion from LV ESV

Characterise disease

Select surgeon Barlow

Anterior leaflet / bi-leaflet

Help surgeon decide strategy Minimally invasive - right thoracotomy (not in Barlow)

Resection (P leaflet) / excess tissue repositioning (A leaflet) Neo-chords (both leaflets)

Annulus size (bigger in Barlow)

3D echo => electronic dissection Example: anterior mitral valve leaflet cleft & ostium primum ASD

3D makes it easy

Anonymised

Ostium primum / TV-MV planes

A2A3 anterior MVP nut-shell like leaflet, non-pliable, long chords myxomatous & fibrosed ?distinct pathological entity

Anonymised

Relative prolapse restricted P2

Colour flow – differential diagnosis jet origin + jet direction

Characterise disease

BARLOW FIBROELASTIC DEFICIENCY

Thick leaflets Extensive tissue redundancy

Multi-scallop / multi-segment prolapse Leaflet “atrialisation”

Thickened / elongated / ruptured chords Dilated annulus

More circular annulus

Thin leaflets No tissue redundancy

Single scallop / segment involvement Prolapsing / flail involved segment

Elongated / ruptured involved chords Annulus < 32 mm

Oval shaped annulus

+ Forme fruste

Co-existent pathology

Adapted from Anyanwu & Adams Semin Thorac Cardiovasc Surg 2007

Characterise disease – experience / quantification P2

? Only P2 or complex disease

Characterise disease – experience / quantification P2

? Only P2 or complex disease visual assessment compares with background

3D Mitral Valve

Quantification

Normal Billowing height

< 1mm

Degenerative MV disease

Billowing height > 1mm

Barlow Billowing volume

> 1.15ml

Fibroelastic deficiency

Billowing volume < 1.15ml

S. Chandra et al. (R. Lang) Circ Cardiovasc Imaging 2011

3D MVQ bonus

Anterior leaflet length

Posterior leaflet length (ratio)

Aorto – mitral angle

…

Fibroelastic deficiency

FED P2

Courtesy Prof David Adams, Mitral Valve Repair Reference Centre, Mount Sinai Hospital, New York

FED P2 Triangular Resection Gap closure

True size 26mm Physio Annuloplasty ring

Barlow valve

Barlow P3

BARLOW P2

BARLOW P2

BARLOW P2 sliding plasty

Quadrangular resection P2

Sliding leaflet plasty

Neo-chord to P2

True size 35mm ATS Simulus

Annuloplasty Band

Multi-segmented Barlow’s

Multi-segmented Barlow’s

1.15ml surgeon ? flail P2, elderly patient

FED P2

Mitral valve surgeon ? Young patient, asymptomatic

Barlow / FF P2

Bi-leaflet involvement “mitral surgeon” job

Before and after assessing the method

Relative anterior leaflet prolapse (restricted posterior leaflet) MVQ experience back-up / substitute

CONCLUSION

Imaging of the mitral valve

morphology / pathology assessment

LV assessment

helps guide the patient towards the right surgeon

may help plan the procedure