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The Changing Left Ventricle

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Surgical Anatomy of the Mitral Valve
The diagram at the left views the mitral valve from the rear. Note there are two papillaries.
The posterior leaflet is the widest around the annulus and divided into three scallops, P1, P2, P3. P1 is adjacent to the antero-lateral commissure and is closest to the aorta (anterior). The opposing sections of the anterior leaflet are designated A1, A2 and A3. Thus, there are eight places for functional abnormalities to occur (two commissures and 6 of the previously noted leaflet sections).
The mitral annulus is opened and viewed from posteriorly. Note the three scallops of the posterior leaflet.
A fresh porcine heart is opened to show the same anatomy depicted in the diagram of the previous figure.
The functional segments shown from the surgical approach (left) and the chest wall (right). Surgery views things from above (the left atrium) and echo from below. Note the position of the aorta to help orient the most anterior commissure and thus, P1.
The mitral valve functional segments viewed by echo (from below). Note the aortic position to help identify segments. The right shows a pathologic section depicting the echo view.
The two echo views. From the chest wall (left) and the TEE approach (right). Note the position of the aorta to help orient the most anterior commissure and thus, P1.

View Mitral Valve Anatomy video

Pathology
Pathologic specimen showing the ventricular side of a St. Jude’s prostheses with vegetative growths (left). The right shows the same specimen from the atrial surface showing a vegetation through the prostheses (arrow).
Pathologic specimen of the mitral valve cut from the side. Note the scallops and compare to the diagrams and specimens in the section on anatomy. The arrow points to a vegetation on chords of the posterior mitral valve leaflet (P3 segment).
Pathologic speciment of the mitral valve cut from the side in a patient with typical mitral valve prolapse. The leaflets are thickened (arrow).
Pathologic specimen of the mitral valve cut from the side in a patient with broken mitral chordae (arrow). The chords segment shown has ruptured chords to P1. 
Pathologic specimen of the mitral valve cut from the side in a patient with typical rheumatic mitral stenosis. The leaflets are thickened and the chordae are shortened.
Even more severe mitral stenosis in comparison to the previous figure. The arrow points to severe chordal thickening and shortening.
An eroded mitral valve leaflet from bacterial endocarditis (arrow). Where is the erosion. Answer is at the base of P2. The pathologic specimen is cut from the side.
Severe dysplastic changes of the posterior mitral leaflet (arrow). Note the leaflets and chordae are indistinct.
A mitral valve specimen shown cut from the side. Which is the anterior mitral leaflet. Correct answer is at the right hand side. Not it is the longest in length, but the narrowest around the annulus. The mitral morphology is normal. See the next figure.
A short axis of the left ventricle from the patient shown in the previous figure. While the morphology of the mitral valve was normal, note the significant wall thinning a the bottom that followed an infarction. This patient has severe MR with failure to coapt.

View Echo Cases of MR (no audio)

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