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20. Ranganathan N, Silver MD, Robinson TI, Kostuk WJ, Felderhof CH,Patt NL, Wilson JK, Wigle ED: Angiographic-morphologic correlationin patients with severe mitral regurgitation due to prolapse of theposterior mitral valve leaflet. Circulation 48: 514, 1973

21. Ranganathan N, Silver MD, Wigle ED: Mitral valve prolapse. Circula-tion 49: 1268, 1974

22. Grossman H, Fleming RJ, Engle MA, Levin AH, Ehlers KH: Angiocar-diography in the apical systolic click syndrome. Radiology 91: 898, 1968

23. Ehlers KH, Engle MA, Levin AR, Grossman H, Fleming RJ: Left ven-tricular abnormality with late mitral insufficiency and abnormal electro-cardiogram. Am J Cardiol 26: 333, 1970

24. Leachman RD, De Francheschi A, Zamalloa 0: Late systolic murmursand clicks associated with abnormal mitral valve ring. Am J Cardiol 23:679, 1969

25. Gooch AS, Vicencio F, Maranhao V, Goldberg H: Arrhythmias and leftventricular asynergy in the prolapsing mitral leaflet syndrome. Am J Car-diol 29: 611, 1972

26. Liedtke AJ, Gault JH, Leaman DM, Blumenthal MS: Geometry of left

ventricular contraction in the systolic click syndrome. Circulation 47: 27,1973

27. Gulotta SJ, Gulco L, Padmanabhat V, Miller S: The syndrome ofsystolic click, murmur, and mitral valve prolapse - a cardiomyopathy?Circulation 49: 717, 1974

28. Scampardonis G, Yang SS, Maranhao V, Goldberg H, Gooch AS: Leftventricular abnormalities in prolapsed mitral leaflet syndrome. Circula-tion 48: 287, 1973

29. Nutter DO, Wickliffe C, Gilbert CA, Moody C, King SB: Thepathophysiology of idiopathic mitral valve prolapse. Circulation 52: 297,1975

30. DeMaria AN, King JF, Bogren HG, Lies JE, Mason DT: The variablespectrum of echocardiographic manifestations of the mitral valveprolapse syndrome. Circulation 50: 33, 1974

31. Ranganathan N, Lam JHC, Wigle ED, Silver MD: Morphology of thehuman mitral valve. II. The valve leaflets. Circulation 41: 459, 1970

32. Altieri PI, Witt SM, Leighton RF: Left ventricular wall motion duringthe isovolumic relaxation period. Circulation 48: 499, 1973

Mitral Valve ProlapseTwo-dimensional Echocardiographic and Angiographic Correlation

BRIAN W. GILBERT, M.D., F.R.C.P. (C),RICHARD A. SCHATZ, OLAF T. VONRAMM, PH.D.,

VICTOR S. BEHAR, M.D., AND JOSEPH A. KIsSLO, M.D.

SUMMARY In order to define baseline descriptive criteria for thediagnosis of mitral valve prolapse with cross-sectional echocardiog-raphy, 49 patients undergoing catheterization were examined by areal-time, two-dimensional phased array echocardiographic imagingsystem. Angiography was used to separate patients into two distinctgroups: 15 with normal mitral valve function and 34 with definitemitral valve prolapse. Systolic mitral leaflet and annulus motion werethen observed in each patient and similarities and differences werenoted between the two groups of patients. Correlative M-mode echo-cardiographic data were available in 37 patients.

IN RECENT YEARS, conventional time-motion echocar-diography has become widely accepted as a useful methodfor the detection of mitral valve prolapse.1-5 Despite thispromising application, some investigators" have expressedconcern over the sensitivity and specificity of the time-motion echocardiographic criteria that define this entity.

Two-dimensional, or cross-sectional, echocardiography,because of its unique ability to provide spatial informationregarding cardiac structures, shows promise for the accuratenoninvasive detection of patients with the mitral valveprolapse syndrome. At the present time, however, there areno reasonable descriptive criteria for the diagnosis of mitral

From the Cardiovascular Laboratory, Department of Medicine, and theClinical Cardiology Laboratory, Duke University Medical Center, Durham,North Carolina.

Supported in part by USPHS Grants HL 12715-07, HL 14228, HL 17670-01, and HS 01613. Dr. Gilbert is supported by the Canadian Heart Founda-tion.

Dr. Gilbert's present address is Noninvasive Laboratory, Department ofCardiology, Toronto General Hospital, 101 College Street, West, Toronto,Ontario, Canada M5G IL7.

Address for reprints: Joseph A. Kisslo, M.D., Box 3818, Duke UniversityMedical Center, Durham, North Carolina 27710.

Received March 30, 1976; revision accepted June 7, 1976.

Certain two-dimensional echocardiographic findings restrited tothe angiographically proven mitral valve prolapse group were defined:1) posteriorly displaced coaptation of the leaflets, 2) systolic superiormovement of one or both mitral leaflets above the level of the mitralring, and 3) a systolic curling motion of the posterior mitral ring onits adjacent myocardium. One or more of these abnormalities werefound in all 34 patients with angiographic mitral valve prolapse.When mitral valve prolapse does occur, the results of two-dimensionalechocardiography would suggest that both leaflets are usually in-volved.

valve prolapse using this technique. Most importantly, thereis no existing information regarding the two-dimensionalechocardiographic-angiographic correlates observed in pa-tients witS mitral valve prolapse.The purpose of this study was to compare the two-

dimensional echocardiographic (2-D echo) appearance ofmitral leaflet motion in patients with and without angiogra-phically proven mitral valve prolapse. From this informa-tion, baseline descriptive criteria for the diagnosis of mitralvalve prolapse by 2-D echo were formed.

MethodsPatients

One hundred eighty-three consecutive patients underwentcomplete clinical, 2-D echo, and angiographic examinationin a three-month period for the diagnosis of various forms ofheart disease. Of these, 49 patients were selected for thisstudy on the basis of catheterization. These patients hadeither normal mitral valve function or mitral valve prolapseon cineangiogram and had 2-D echoes suitable for theanalysis of mitral leaflet motion throughout the cardiac cy-cle. Twenty-eight patients were catheterized specifically for

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the diagnosis of angina-like chest pain. Selected clinical dataconcerning reasons for catheterization, physical examina-tion and resultant hemodynamic data in these two groups ofpatients are summarized in table 1. The patients weredivided into two groups. In group I, 15 patients, the resultsof catheterization failed to reveal evidence for heart disease.In group II, 34 patients, the results of catheterizationrevealed unequivocal angiographic evidence of mitral valveprolapse.

Catheterization Methods

All patients underwent complete left and right heartcatheterization using the Seldinger technique. Intracardiacpressures were recorded in a standard fashion and cardiacoutput was determined by the Fick method. Biplane left ven-tricular cineangiograms were obtained with the patients in aslight right anterior oblique position using a mixture of 66%meglumine diatrizoate and 10% sodium diatrizoate (Re-nografin-76). Selective coronary cinearteriography was per-formed in all patients. Significant coronary artery diseasewas defined as a 75% or greater stenosis of one or more ma-jor coronary vessels. Left ventricular cineangiograms wereindependently analyzed for evidence of mitral prolapse7-1"and the presence and severity of mitral regurgitation. Mitralprolapse was noted when one or both of the mitral leafletswas seen moving into the left atrium in systole in both rightanterior and left anterior oblique views. The results ofangiography were agreed upon by two angiographers.

Echocardiographic Methods

Two-dimensional echoes were obtained using a previouslydescribed12' 13 real-time, phased array imaging system de-veloped in the Duke University Biomedical Engineering De-partment that is currently undergoing clinical evaluation inthe Duke University Department of Medicine.This imagingsystem uses a hand-held, 24 element 2.25 MHz transducerarray that measures 14 X 24 mm at the site of skin contactand relies upon phased array principles to electronicallysteer the sound beam through the structures under investiga-

TABLE 1. Summary of Clinical Data

Group IIGroup I MitralNormals prolapses(N =15) (N =34)

PatientsAge (yr) 44 8 47 15Male:female 7:8 19:15

Reason for catheterizationChest pain 14 14Syncope 1 1Shortness of breath 0 19

Physical examinationSystolic click alone 0 7Systolic murmur alone 9 14Systolic click and murmur 0 13

Catheterization dataLVEDP (mm Hg)

Mean1 SD 10 3 10 ' 5Range (4 - 15) (4 - 15)

Cardiac index (L/min/m2)Mean - SD 3.2 - 0.9 3.1 - 0.5Range (2.3 - 4.0) (1.3 - 5.7)

Abbreviations: LVEDP = left ventricular end-diastolic pressure.

tion. Real-time cross-sectional images of cardiac structuresare presented in a circular sector format, 50, 60, or 90degrees in azimuth. Images are permanently recorded onvideotape for later playback and analysis.

Figure 1 schematically shows the plane of view used forexamination of the long axis of the mitral valve and left ven-tricle. This view was obtained using previously describedtechniques.'3 Note that the plane of the sector arc ideally in-tercepts the aortic root, left atrium, long axis of the mitralvalve and left ventricle. A systolic single-frame photographand schematic illustration of a normal mitral valve areshown in figure 2.

It is important to note that the single-frame images of thevideotape recordings were made by means of a 35 mmphotograph of the sector arc in a stop-frame mode. As such,there is a loss of visual integration of motion that normallyaccompanies real-time playback. Moreover, during stop-frame mode, there is a severe degradation in image qualitycaused by photographing a single field of a complete video-tape frame which consists of two interlaced fields. For exam-ple, an individual videotape recording frame represents thescan information collected in only 1/60 of a second. Whenoperating in the 90-degree, 160-line format, therefore, each

FIGURE 1. Schematic diagram showing the plane of view throughthe long axis of the left ventricle. This view normally intercepts theaortic root, left atrium, mitral valve and left ventricle. Arrows il-lustrate systolic rotation of the heart which would alter the view ofstructures.

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FIGURE 2. Panel A shows a photo from a stop action videotapeframe through the long axis of the normal left ventricle duringsystole. Panel B is the schematic illustration ofpanel A. The openarrow indicates the normal obtuse angle between the atrial surfaceof the anterior mitral leaflet and the posterior aortic root wall.AR = aortic root; AL = aortic leaflet; IVS = interventricular sep-tum; LV = left ventricular cavity; LA = left atrium;AML = anterior mitral leaflet; PML - posterior mitral leaflet;C chorda; PW= posterior wall.

single frame video field represents only one-half (80 lines)the information provided in the actual scan or in real-timeplayback.

All echoes were obtained within one day of cardiaccatheterization. The 2-D echo appearance of the mitral valveleaflets, the systolic mitral ring motion and the adjacent leftventricular wall movement were analyzed. In addition,quantitative assessment of the point of early systolic coapta-tion of the mitral leaflets was obtained by measuring the dis-tance from the anterior echo of the posterior aortic root atits junction with the mitral leaflet (mitral ring) to the pointof leaflet coaptation (fig. 3). The point of anterior measure-

ment moved with the aortic root rather than the mitralleaflet. Discrete echoes from the anterior surface of theanterior mitral leaflet were often obscured by multipleechoes due to leaflet curvature of chordal structures. Thepoint of initial leaflet coaptation was, therefore, chosen as

the position for posterior measurement since it could bemost easily identified. This calculated index is notablysimilar to that previously used by Johnson'4 in time-motionechocardiography.Time-motion echocardiograms were obtained in most

patients (37 of 49) using previously described techniques.'Particular care was taken to assess mitral leaflet systolic

FIGURE 3. Schematic diagram through the long axis of the leftventricle showing normal mitral leaflet coaptation with no leafletmovement above the level of the mitral annulus and normalposterior coaptation of the leaflets.

contour with the transducer positioned perpendicularly onthe chest wall according to the method of MarkiewiCz.6Echocardiographic sweeps were performed with thetransducer initially held perpendicular to the mitral leafletsand then angled superiorly to the aortic root. Measurementof posterior leaflet coaptation was made from the posterioraortic root wall to the point of the leaflet coaptation in earlysystole." The presence or absence of mitral prolapse wasdetermined using previously published criteria.'-' Thirty ofthe time-motion examinations were performed using a com-mercially available M-mode ultrasonoscope while the re-maining seven had this examination performed simulta-neously with the 2-D echo using the recently added lineselectable M-mode feature of the cross-sectional scanningsystem.

ResultsGroup I

Two-dimensional ultrasound showed that in diastole theanterior leaflet of the mitral valve opened downward andanteriorly, while the posterior mitral leaflet moved againstthe posterior left ventricular wall. With the onset of systole,the anterior leaflet moved posteriorly and the posteriorleaflet moved anteriorly, coapting and creating a funneledappearance (fig. 2). Through systole, both leaflets archedslightly toward each other and the entire mitral apparatusdescended in an anterior inferior direction. Slight posteriorcurvature of the anterior mitral leaflet during systole wasquite normal. During systole, there was never a superiormovement of the leaflets above the level of the atrioventric-ular ring (fig. 3). Reliable measurements of the point ofleaflet coaptation behind the posterior aortic root wall couldbe made in 12 of the 15 patients and averaged 0.5 ± 0.2 cm(range 0.2 to 0.7 cm). Since the degree of posterior coapta-tion was minimal in these patients, there was only slightangulation noted between the posterior aortic root andanterior mitral leaflet in systole (fig. 2 - arrow). In addi-tion, the posterior mitral ring and its adjacent left ventric-ular wall moved anteriorly and downward in systole in syn-chrony with the remainder of the left ventricle. In allpatients, left atrial size was normal (less than 4 cm).

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Group II

No patient had angiographic evidence of significant cor-onary artery disease. Seventeen patients had severe mitralinsufficiency by cineangiography, four had mild mitral in-sufficiency, and in 13 patients there was no mitral insufficien-cy. Twenty-three patients had angiographic evidence ofcombined anterior and posterior mitral leaflet prolapse,while 11 patients had angiographic evidence of prolapse ofthe posterior leaflet alone. No instance of isolated prolapseof the anterior mitral leaflet was seen.10

Two-dimensional echocardiography demonstrated exces-sive posterior closure of the coaptation point of the mitralleaflets (mean ± SD, 1.4 ± .05 cm, range 0.6 to 2.4) (fig. 4)as the most common finding (table 2). Only one patient hada closure point less than 0.8 cm behind the posterior aorticwall. The displaced posterior closure resulted in an accen-tuation of the angle formed by the posterior aortic root andthe anterior mitral leaflet in systole (fig. 4B - arrow).Superior arching of the anterior and/or posterior mitralleaflets above the level of the mitral ring (figs. 5 and 6) wasconsidered positive evidence of mitral leaflet prolapse.Twenty-four patients had unusual systolic curling of the

TABLE 2. Frequency of Manifestations ofby Two-Dimensional Echocardiography

Mitral Prolapse

Displaced posterior coaptation 33Anterior leaflet prolapse

Superior leaflet arching 30Posterior leaflet prolapse

Superior leaflet arching 9Ring curling 14Arching and curling 10

posterior mitral ring on the adjacent myocardium. In nor-mals, the posterior mitral ring moves downward andanteriorly in systole. In those patients with mitral prolapseand ring curling, the systolic movement of the ring wasprimarily downward with little, if any, anterior motion, thusresulting in a curled appearance when visualized in real-timeplayback. The left atrium was dilated in ten patients (greaterthan 4 cm).When superior systolic movement of either mitral leaflet

above the level of the mitral ring was severe, that leafletappeared rather large and manifested a whip-like motionduring early diastole as the leaflet opened. This exaggeratedexcursion of the mitral leaflet is illustrated in figure 7. Therapid change of position of the anterior mitral leaflet (panelsC and D) from its position 1/30 second earlier (panels A andB) is shown.The results of standard M-mode echocardiography are

summarized in table 3. Most importantly, there were sevenpatients in group II without detectable M-mode evidence formitral prolapse using currently accepted criteria.'`6 Four of

FIGURE 4. Panel A shows a systolic frame through the long axisof the left ventricle in a patient with angiographically provenprolapse of the mitral valve. Note the excessive coaptation of theanterior andposterior mitral leaflets and the decreased (more acute)angle between the atrial surface of the anterior mitral leaflet and theposterior aortic root wall. Panel B is the schematic illustration ofpanel A.

FIGURE 5. Scan of a patient displaying excessive superior move-ment of the anterior mitral leaflet above the plane of the atrio-ventricular ring. Panel B is a schematic illustration ofpanel A.

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K>~PPLP

AA-

,-AML MA

..C

.)pt.,

AA

MA-

PLP

FIGURE 6. Panel A shows a systolic frame displaying excessive superior movement ofthe posterior mitral leaflet abovethe level of the mitral valve ring. Panels C and E represent the left anterior oblique (LAO) and right anterior oblique(RA 0) angiographic views ofthe posterior leaflet prolapse. Panels B, D, and F are schematic representations ofpanels A,C, and E, respectively. AA aortic annulus; MA = mitral annulus; PLP = posterior leaflet prolapse.

FIG,URE 7. Panels A and C show diastolic scans two frames apart (1/30 second) illustrating the rapid whipping motionof the mitral leaflets in early diastole. Panels B and D are schematic illustrations ofpanels A and C, respectively.

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TABLE 3. Results of M-mode EchocardiographyPansystolic Late systolic

Normall-6 hammock posterior motion Total

Group I 8 0 0 8Group II 7 8 14 29

these patients had M-mode examinations performed wheremultiple areas of the mitral leaflets were examined using thesimultaneous M-mode feature of the cross-sectional imagingsystem. Of the 37 patients with M-mode examinations, 26(all in group II) did show M-mode echocardiographicevidence for displaced posterior closure of the mitral valve insystole.

Echocardiographic-Angiographic Correlations

The 2-D echo-angiographic correlations regarding thespecific leaflet involved in the mitral prolapse are sum-marized in table 4. All 34 patients in group II had 2-D echoevidence of mitral prolapse. It is important to note that 2-Decho suggested additional prolapse of the anterior mitralleaflet in nine of the eleven patients with angiographicevidence for posterior prolapse alone. In only one case didthe 2-D echo fail to identify angiographic prolapse of theposterior mitral leaflet.

In general, when posterior mitral leaflet prolapse wasjudged severe by angiogram, a significant superior systolicarching of the posterior leaflet was seen on 2-D echo (fig. 6).When posterior leaflet arching was less severe on angiog-raphy, minimal or no superior motion was seen on 2-D echoand systolic curling of the posterior mitral ring on theposterior myocardium was the only sign suggesting posteriormitral leaflet prolapse. Similarly, when anterior mitralleaflet prolapse was judged severe by angiogram, superiorsystolic arching of the anterior mitral leaflet was significanton 2-D echo (fig. 5). It is important to note, however, thatminor degrees of arching of the anterior mitral leaflet abovethe level of the mitral ring were seen in nine patients withoutangiographic evidence of anterior mitral leaflet prolapse.

In the four patients with mild mitral regurgitation byangiography, both the anterior and posterior mitral leafletswere seen to prolapse by both techniques. Similarly, 13 ofthe 17 patients with severe mitral regurgitation byangiography had anterior and posterior leaflet prolapsedemonstrated by angiography and 2-D echo. Three of theremaining four patients showed isolated posterior leafletprolapse by angiography but combined leaflet prolapse by2-D echo. One patient showed prolapse of both leaflets byangiography but only posterior leaflet prolapse by 2-D echo.All ten patients with left atrial dilatation by 2-D echo had

TABLE 4. Angiographic and Two-dimensional Echzocardio-graphic Correlaion of Mitral Prolapse

Prolapse by angiographyAnterior and Posterior Anterior

posterior leaflets leaflet leaflet(N = 23) (N = I1) (N = O)

Prolapse by echoAnterior and

posterior leaflets 21 8 0Posterior leaflet 2 2 0Anterior leaflet 0 1 0

severe angiographic mitral regurgitation. While quantita-tive data were not available on all patients, left ventricularwall motion was assessed in qualitative terms by Gorlin'scriteria"5 and no abnormalities were seen by either cinean-giography or 2-D echo.

Discussion

Mitral prolapse is a relatively common cardiac valvularabnormality.6' 16'" Since the initial descriptions of the time-motion echocardiographic appearance of mitral prolapse byShah' and Dillon,' this technique has become a usefulmethod for the noninvasive detection of patients with thisentity. As clinical experience has grown, however, severalauthors6' 20 have demonstrated limitations in the specificityof time-motion echocardiography for the diagnosis of thisdisorder. Weyman," Henry," and Kisslo" and others'8 havedemonstrated the initial applications of cross-sectional echo-cardiography for the detection of a variety of cardiac dis-orders. Although Sahn24 has recently reported real-time,cross-sectional echocardiographic data in children withmitral prolapse, there are no reports of two-dimensionalechocardiographic and angiographic correlations in patientswith this entity.

It should be noted that there are several limitations to thisstudy. First, no attempt has been made to test either the sen-sitivity or the specificity of two-dimensional echocardiog-raphy in detecting mitral prolapse. It is possible thatpatients with angiographically undetectable mitral prolapsewere included in group I. The results of this study simplyserve to describe certain common features in the 2-D echocharacteristics of mitral leaflet motion in normal patientsand in those with angiographically proven mitral valveprolapse. Second, in patients with prolapse examined in thisstudy, the prolapse was most often severe. Of the 34 patientswith prolapse, 17 had severe mitral insufficiency. This pop-ulation was, of course, highly selected, as it is based solelyon catheterized patients. It is important to recognize,however, that in the 13 patients with mild or moderateprolapse and no angiographic evidence for mitral insufficien-cy, 2-D echo evidence for displaced posterior closure,systolic superior leaflet .motion, or curling of the posteriormitral ring were still present. Third, 2-D echo, like all pulsedultrasonic techniques, is somewhat limited in its appli-cability to all patients due to poor sound transmissioncharacteristics induced by abnormal chest wall configura-tion, patient age, or the presence of interposed lung. Clinicalexperience with real-time, two-dimensional echocardiog-raphy in this laboratory in nearly 1,000 consecutive, un-selected patients has revealed that an unsatisfactory 2-Decho of the mitral leaflets is obtained in approximately 10%of examinations. Fourth, correlative M-mode and 2-D echodata were available in only 37 of the 49 patients in this study(table 3). All patients in group I examined by standardM-mode technique were completely normal. Of interest isthe fact that seven patients in group II also failed to showM-mode evidence of prolapse by currently accepted crite-ria.'-6 There was no obvious relationship between themorphology of mitral prolapse seen on either 2-D echo orangiography and abnormalities noted on M-mode. Twenty-six of the twenty-nine patients in group II, however, didshow evidence for displaced posterior coaptation in systole.

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Although the numbers are still relatively small, these findingsmay suggest that 2-D echo is more sensitive than M-modein detecting mitral prolapse when criteria concerning mitralsystolic contour alone are used. Further studies seekingto define the interrelationships of 2-D echo and M-mode arepresently underway.The most common 2-D echo feature (table 2) of mitral

prolapse was displaced posterior coaptation of the mitralleaflets 0.8 cm or greater beyond the posterior aortic root(fig. 4). In the case of anterior leaflet prolapse, when theleaflet is large and redundant, this possibly comes aboutsecondary to excess leaflet tissue. With posterior mitralleaflet prolapse, this abnormality is likely brought about as aresult of the superior motion of the posterior leaflet, drawingthe anterior leaflet markedly posteriorly in early systole. Itshould be understood that the measurement of displacedposterior coaptation of the mitral leaflets in patients withmitral prolapse should not serve by itself to differentiatepatients with normal valve motion from those with prolapse.Rather, this quantitative index was applied in this studypurely to provide a means for expressing the markedly dis-ordered valve closure seen in these patients. Unfortunately,the reliability of any echocardiographic measurement islimited by resolution, gain setting, and/or other factors thataffect the quality of the ultrasonic image. The ultimateutility of this measurement remains to be proven by prospec-tive investigations in larger series of patients.The most reliable indicator of mitral prolapse should re-

main superior motion of either one or both mitral leafletsabove the level of the mitral ring in systole. Whenangiographic prolapse is severe, this 2-D echo finding willalso be severe and the involved leaflet will appear large andredundant. Also with severe prolapse, during early diastole,as the leaflets first move downward into the ventricle, awhip-like motion is present (fig. 7) near the tip of the in-volved leaflet.When the degree of angiographic anterior prolapse is

minor, superior motion of the anterior mitral leaflet isusually seen on 2-D echo. In fact, superior arching of theanterior mitral leaflet by 2-D echo suggesting anterior mitralleaflet prolapse appears more common than is evident byangiography. In this study, nine patients had anterior mitral

LA

ARY

Ivs-= M

frHPOSTERIOR iCOAPTATION

Pw- - 2 cm

NORMAL

leaflet prolapse by 2-D echo that was not seen by angiog-raphy. One must keep in mind the normal anatomy of themitral valve as described by Ranganathan et al.26 Becausethe anterior mitral leaflet has greater height than theposterior leaflet, it is more easily seen by 2-D echo. Despitethis disparity in height, however, the anterior leaflet is fre-quently difficult to define by angiography due to the fact thatit is superimposed on the opacified silhouette of the left ven-tricle. On the other hand, the posterior leaflet has a wider at-tachment to the atrioventricular ring than the anteriorleaflet, and this, coupled with the fact that it is viewed inprofile in the left anterior oblique position, renders it easilyvisible by angiography. DeMaria4 and others have previ-ously pointed out some of the problems in assessing mitralvalve prolapse with cineangiography.When angiographic posterior prolapse is minor, superior

motion of the posterior leaflet is either minimal or not evi-dent and one must rely on the abnormal curling of the mitralring on the adjacent posterior myocardium before prolapsecan be suggested by two-dimensional echo. Curling, asdefined in this study, relates to abnormal annulus motion inan inferior direction relative to its adjacent myocardium. Itis important to note that this curling motion can only be ap-preciated when the cross-sectional echocardiograms areplayed in real-time. The specific etiology of this visually ap-parent curling remains uncertain since we did not visualizeleft ventricular wall motion abnormalities by 2-D echo or byangiography, as have been previously reported by otherauthors.26-28

Although it was not possible to identify specific scallops ofthe posterior mitral leaflet by 2-D echo, it was possible toidentify localized differences in the manifestations of mitralprolapse. The arrows in figure I demonstrate the rotationalmovements of the heart through the 2-D echo plane that oc-cur with the cardiac cycle. Thus, it is possible that portionsof the mitral valve visualized in early systole may rotate outof the plane of view in mid or late systole. Correct 2-D echotechnique is therefore important for the determination ofmitral prolapse, as small angulations in transducer positionmay result in markedly differing appearances of the mitralapparatus. For example, slight lateral angulation of thetransducer may show only minor posterior prolapse. As the

ANTERIORARCHING

II

POSTERIORARCHING

ANTERIOR ARCHINGSUPERIOR MOVEMENT

COMBINEDANTERIOR &

POSTERIOR

T- .

POSTERIOR ARCHINGSUPERIOR MOVEMENT

SPECTRUM OF MITRAL VALVE PROLAPSEFIGURE 8. Schematic diagram of a normal mitral valve and the spectrum of the mitral valve prolapse.

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transducer is then swept medially across the valve structures,the displaced posterior coaptation and severe anterior andposterior prolapse become evident. Figure 8 illustrates themultiple patterns of mitral prolapse that may be seen bytwo-dimensional echo and points out that one or morepatterns may be evident in any one patient. It is recom-mended that the entire mitral valve be carefully examined bysweeping the 2-D echo plane laterally to medially so that allabnormalities may be detected.

It should, however, be noted that if the transducer isangled medially and tangentially across the mitral orifice innormals, false posterior coaptation and minor superiorarching of the anterior mitral leaflet may result. In this case,the anterior-posterior diameter of the mitral ring appearsnarrow and posterior leaflet motion remains normal.

In conclusion, in patients with angiographically demon-strated mitral valve prolapse, it appears that certain abnor-malities of mitral valve motion are evident by two-dimensional echocardiography: 1) posteriorly displacedleaflet coaptation, 2) systolic movement of one or bothmitral leaflets above the level of the mitral ring, and 3)systolic curling motion of the posterior mitral ring on its ad-jacent myocardium. One or more of these abnormalities wasfound in all 34 patients with mitral valve prolapse examinedin this study. Future application of this new ultrasonic imag-ing technique, however, will depend upon further study ofthe sensitivity and specificity of these criteria in largenumbers of patients with suspected mitral prolapse syn-drome.

Acknowledgment

The authors wish to thank Mrs. Robyn Haney and Mrs. Elaine Veazey fortheir assistance in the preparation of this manuscript.

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prolapse. Circulation 42 (suppl II): 11-45, 19702. Kerber RE, Isaeff DM, Hancock EW: Echocardiographic pattern in

patients with the syndrome of systolic click and late systolic murmur. NEngl J Med 283: 691, 1971

3. Dillon JC, Haine CL, Chang S, Feigenbaum H: Use of echocardiog-raphy in patients with prolapsed mitral valve. Circulation 43: 503, 1971

4. DeMaria AN, King JF, Bogren HG, Lies JE, Mason DT: The variablespectrum of echocardiographic manifestations of mitral valve prolapsesyndrome. Circulation 50: 33, 1974

5. Popp RL, Brown OR, Silverman JF, Harrison DC: Echocardiographicabnormalities in mitral valve prolapse syndrome. Circulation 49: 428,1974

6. Markiewicz W, Stoner J, London E, Hunt SA, Popp RL: Mitral valve

prolapse in one hundred presumably healthy young females. Circulation53: 464, 1976

7. Ranganathan N, Silver MD, Robinson TI, Kostuk WJ, Felderhof CH,Patt NL, Wilson JK, Wigle ED: Angiographic-morphologic correlationin patients with severe mitral regurgitation due to prolapse of theposterior mitral valve leaflet. Circulation 48: 514, 1973

8. Trent JK, Adelman AG, Wigle ED, Silver MD: Morphology of aprolapsed posterior mitral valve leaflet. Am Heart J 79: 539, 1970

9. Kittredge RD, Shimorura S, Cameron A, Bell ALL Jr: Prolapsing mitralvalve leaflets: Cineangiographic demonstration. Am J Roentgenol 109:84, 1970

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B W Gilbert, R A Schatz, O T VonRamm, V S Behar and J A KissloMitral valve prolapse. Two-dimensional echocardiographic and angiographic correlation.

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1976 American Heart Association, Inc. All rights reserved.

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231Circulation doi: 10.1161/01.CIR.54.5.716

1976;54:716-723Circulation. 

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