Anatomy of the mitral valve relative to controversies concerning the so-called annular disjunction

Heart. 2023 Apr 25;109(10):734-739. doi: 10.1136/heartjnl-2022-322043.


It is now accepted that the mitral valve functions on the basis of a complex made up of the annulus, the leaflets, the tendinous cords and the papillary muscles. So as to work properly, these components must combine together in harmonious fashion. Despite the features of the arrangement of each component having been the focus of anatomical investigation for centuries, controversies still exist in their inter-relations and how best to describe them. To a large extent, the ongoing problems reflect the fact that, again for centuries, morphologists when describing the heart have ignored the rule that its components should be described as seen in the body during life. Failure to use attitudinally appropriate descriptions underscores a particular current issue, namely the influence of the so-called disjunction within the atrioventricular junction as a potential substrate for leaflet prolapse or malignant arrhythmias. With these difficulties in mind, we have reviewed how the components of the valvar complex can best be described when comparing direct images with those obtained using three-dimensional techniques now used for clinical imaging. We submit that these show that the skirt of leaflet tissue is best described as having aortic and mural components. When the hinge of the mural leaflet is assessed within the overall atrioventricular junction, the so-called disjunction is ubiquitous, but not always in the same place. We further suggest that its significance will best be determined when clinicians describe its presence using attitudinally appropriate terms.

Keywords: diagnostic imaging; echocardiography; mitral valve insufficiency.

Publication types

  • Review

MeSH terms

  • Arrhythmias, Cardiac
  • Humans
  • Mitral Valve
  • Mitral Valve Insufficiency*
  • Mitral Valve Prolapse*
  • Papillary Muscles