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A new feature in Myxomatous Mitral Valve Disease: Cleft-Like Indentation - Prevalence, mechanisms and implication
francesca mantovani1, Marie-Annik Clavel1, Ori Vatury1, Rakesh M. suri1, Sunil mankad1, Josef F Malouf1, Hector I. Michelena1, Luigi P. Badano2, Maurice Enriquez-Sarano1.
1mayo clinic, rochester, MN, USA, 2Università degli Studi di Padova, Padova, Italy.

Background: Cleft-like indentations of posterior leaflet (CLI) were recently described in Myxomatous mitral valve disease (MVD). However CLI prevalence, mechanisms and implications are unknown. Aims: To investigate 3D-echocardiographic prevalence and mechanisms of CLI in MVD and their implications. Methods: Real-time 3-dimensional transesophageal echocardiography (3D TEE) of the mitral valve was acquired in 49 patients with MVD and severe regurgitation prior to mitral valve repair surgery. CLI was defined echocardiographically as a visible defect seen during systole, extending at least one half of the depth of the adjacent mitral leaflet. 3D prevalence of CLI was compared with surgeon visual inspection. Mitral annular (anteroposterior and intercommissural diameters, area) and leaflets dimensions (3-dimensional area, volume of prolapse) were measured in end-systole with dedicated quantification software. Results: CLI in the posterior leaflet was identified with 3D TEE in 17 (35%) patients. Among them, 15 (88%) were confirmed by surgical visual inspection. Compared to patients without CLI (n=32), those with CLI (n=17) had similar left ventricle end-diastolic diameter (57±6 vs. 57±6 mm; p=0.91) and severity of mitral regurgitation (regurgitant volume 89±56 vs. 79±29; p=0.49). However, patients with CLI had a smaller mitral annulus as documented by antero-posterior diameter (42.2±7.1 vs.47.0±7.5 mm, p=0.04), intercommissural diameter (36.5±4.5 vs.41.4±5.9 mm, p=0.005) and area (1289±326 vs.1619±427 mm2, p= 0.008) compared to patients without CLI. There was also a trend toward a smaller volume of prolapse in patients with CLI (1.9±1.2 vs.4.0±4.3 ml, p=0.06) compared to patients without CLI. Importantly, the global quantity of valve tissue was markedly less in patients with than without CLI (leaflets area 1574±409 vs.2019±652 mm2, p=0.01), especially due to a smaller posterior leaflet area (783±254 vs. 1048±409, p=0.02). The closure of all CLI was required during surgical valve repair. Conclusions: Cleft-like indentations of the posterior leaflet are often present in MVP and are identified purely by 3DTEE, with high accuracy. CLI occur in the context of decrease amount of leaflet tissue especially of the posterior leaflet. Indeed, CLI are unrelated to annular enlargement or excess of tissue. Identification of CLI is important as these defects may require surgical closure.

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