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Mitral Valve Complex🪂🧐
👉The mitral valve is an integrated apparatus composed of the anterior and posterior leaflets, saddle-shaped annulus, chordae tendineae, and papillary muscles.
👉The posterior leaflet is organized into P1–P3 scallops, with corresponding A1–A3 segments of the anterior leaflet forming the opposing coaptation zones.
👉Leaflet coaptation is stabilized by primary and secondary chordae arising from the anterolateral and posteromedial papillary muscle groups.
@PWesslyMD @SIwa23288585 @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho
💎 #ASEchoJC What is systolic curling?
🫀 Normally, the posterior mitral annulus moves downward and anteriorly during systole.
⚠️ In MVP, excessive leaflet mobility and loss of normal annular mechanics can alter this motion, producing a characteristic "curling" of the basal inferolateral LV wall.
🎯 A marker increasingly linked to the arrhythmogenic MVP phenotype.
#EchoFirst #CardioTwitter #EPeeps #MVP @ASE360 @JournalASEcho
Excellent infographic, @HeartToProve
One of the most practical imaging pearls in MVP:
🎯 Don't diagnose MAD from a single systolic frame.
✅ True MAD persists in diastole
❌ Pseudo-MAD disappears in diastole
#ASEchoJC #EchoFirst #CardioX #MVP @ASE360 @JournalASEcho
@PWesslyMD @LucySafi @PriyaPanday27 @NadeenFaza @ASE360 @JournalASEcho @DavidWienerMD @iamritu @purviparwani @SIwa23288585 @boegel_kelly MAD is a true separation between the LV crest & posterior mitral leaflet/LA junction. Pseudo-MAD mimics this during systole when a voluminous leaflet presses against the LA wall, but it vanishes in diastole. Distinguishing them is key! #ASEchoJC
Great point, @LucySafi !
A TEE pearl we should all practice:
For laterally directed eccentric MR jets, use the TG view to better align CW Doppler with the jet.
🎯 Better alignment = more accurate velocity measurement and MR quantification.
#ASEchoJC #EchoFirst #CardioX #MVP @ASE360 @JournalASEcho
@PWesslyMD @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @DavidWienerMD @iamritu @purviparwani @SIwa23288585 @boegel_kelly @JournalASEcho for eccentric jets that are directed laterally (towards the LAA), when attempting to quantify, I like to get the Doppler velocity from the TG view on TEE. It aligns with the get and avoids underestimation of the peak velocity (avoids overestimation of EROA by pisa)
💎 MR Timing matters.
⚠️ In late-systolic MR, EROA reflects only the peak moment of regurgitation.
🫀 Regurgitant volume often better reflects the true MR burden because it accounts for the entire systolic period.
#ASEchoJC #EchoFirst #CardioTwitter #MVP @ASE360 @JournalASEcho
💎 PISA isn't always hemispheric.
⚠️ Commissural MR jets may have a truncated proximal convergence zone because of the nearby LV wall.
Without correction:
➡️ EROA may be overestimated.
🎯 Use the angle correction:
EROA × θ/180°
#ASEchoJC #EchoFirst #CardioTwitter #MVP @ASE360 @JournalASEcho
💎 MR jets in MVP tell a story.
🫀 MR jets are typically directed away from the prolapsing or flail leaflet.
⚠️ But not always—central jets can occur.
🔑 Understanding jet direction helps localize the underlying pathology.
#ASEchoJC #EchoFirst #CardioX #MVP @ASE360 @JournalASEcho
Such an important point, @HeartToProve 💎
As highlighted in your editorial 👇, not all flails are created equal.
🎯 A flail leaflet should raise suspicion for severe MR—but it is not synonymous with severe MR. An integrated assessment remains essential.
#ASEchoJC #EchoFirst @ASE360 @JournalASEcho #MVP #WhyCMR
@PWesslyMD @ASE360 @JournalASEcho Very important -- flail =/= severe MR! In our data a flail leaflet had 81% specificity for severe MR as defined on CMR >60 mL/50% #ASEchoJC
Thank you to EVERYONE who participated in tonight’s #ASEchoJC! ❤️
Huge shout-outs to our moderators, @NadeenFaza, @PWesslyMD and @HeartToProve, and our guest authors, @LucySafi and @PriyaPanday27.
🔑Key Takeaways on MVP, MR, MAD & Arrhythmic Risk 🫀 #ASEchoJC
✅ MVP affects ~2.5% of the population and is the leading cause of primary MR.
✅ Diagnosis requires ≥2 mm leaflet displacement in the PLAX/long-axis view.
✅ Barlow’s disease ≠ FED:
• Barlow = redundant bileaflet prolapse
• FED = isolated segment prolapse with chordal rupture
✅ MR assessment is tricky—eccentric, multiple, commissural, and late-systolic jets can underestimate severity.
✅ Not all MAD is created equal:
True MAD persists in systole and diastole; pseudo-MAD does not.
✅ MAD and prolapse volume add to LV volume overload beyond MR alone.
⚠️ Arrhythmic MVP can occur even without severe MR.
🚩 Echo markers of increased VA/SCD risk:
• Bileaflet prolapse
• MAD >8.5 mm
• Pickelhaube sign
• Curling
• Mechanical dispersion
• Double-peak strain pattern
🎯 CMR is critical for risk stratification—fibrosis by LGE or elevated ECV identifies patients at higher arrhythmic risk.
See you next #ASEchoJC!
@PWesslyMD @HeartToProve @LucySafi @CASivaram1 @iamritu @purviparwani @ASE360 @JournalASEcho
MVP is increasingly recognized as an annular–valvular–ventricular disease process, making multimodality imaging essential for diagnosis and risk stratification. #ASEchoJC #EchoFirst #CardioX #MVP @ASE360 @JournalASEcho
🔍MVP from a surgical perspective:
🔹 “Prolapse” = displacement of the coaptation zone into the left atrium
🔹 “Billowing” = leaflet body enters the LA while the coaptation zone remains in the LV
An important distinction between true prolapse vs billowing 👀 #ASEchoJC @ASE360 @JournalASEcho #EchoFirst #CardioTwitter #MVP
@PWesslyMD @LucySafi @PriyaPanday27 @HeartToProve @ASE360 @JournalASEcho #ASEchoJC The Pickelhaube sign: Lateral annular S′ ≥16 cm/s associated with ventricular arrhythmias in MVP ⚡️
#EPeeps
👉https://t.co/1nt0u3KMBZ
✨ Huge thank you to everyone who joined tonight's #ASEchoJC!
What an incredible discussion on MVP, MR, MAD, ventricular arrhythmias, and the evolving concept of arrhythmic MVP. 🫀⚡️
Grateful to our outstanding guest authors Dr. Jeffrey Silbiger @LucySafi, @priyaPanday27, and for sharing their expertise and insights, and to my wonderful co-moderators @NadeenFaza and @HeartToProve. A special thank you to our #EchoFirst enthusiasts and engaged audience for contributing to such a lively, thoughtful, and high-yield discussion.
Proud to be part of this amazing global #EchoFirst community! 💙🌍 @ASE360 @JournalASEcho
@PWesslyMD @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho Papillary muscle traction from the MVP also pulls the basal lateral wall in the apical direction. This brisk motion causes a prominent s’ wave on tissue Doppler imaging. An s’ > 16 cm/s is called the Picklehaube sign
@PWesslyMD @LucySafi @PriyaPanday27 @NadeenFaza @ASE360 @JournalASEcho Our group also identified a novel Doppler sign —Bifid-E wave— that could represent an additional echocardiographic marker of advanced MVP and myocardial fibrosis. Keep an eye out for this next time you're reading a Barlow Echo. #ASEchoJC
#ASEchoJC 🫀 Is this patient a good candidate for M-TEER?
#EchoFirst holds the answer 💡. 🔑 features that guide candidacy and device selection include:
✅ 3D mitral valve area
✅ Posterior leaflet length
✅ Baseline transmitral gradient
✅ Prolapse/flail location
✅ Flail gap and width
✅ Barlow’s disease
✅ Calcification in the grasping zone
The procedure starts long before the procedure—at the #EchoFirst workstation. #CardioTwitter #Echofirst #MTEER🫀📸
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