Mitral valve training › Guides › Cleft of the anterior leaflet

Cleft anterior mitral leaflet on echocardiography

What to look for: Normal motion; the jet starts in the anterior leaflet (PSAX).

Key findings

• A cleft is a slit through a leaflet, classically the anterior leaflet; the leaflets move normally (type I).
• Parasternal short axis at the leaflet level shows it en face: the jet starts in the body of the leaflet, not along the coaptation line. 3D echo or TOE confirms it.
• In a long-axis cut through the cleft the anterior leaflet can look short or deficient, and the jet is often eccentric.

Grading the regurgitation (primary MR)

• Severe: vena contracta ≥7 mm, EROA ≥0.40 cm², regurgitant volume ≥60 ml, regurgitant fraction ≥50%. Mild: vena contracta <3 mm, EROA <0.20 cm², regurgitant volume <30 ml.
• Specific signs of severe MR: a flail leaflet or ruptured papillary muscle, a large flow convergence, and systolic flow reversal in the pulmonary veins; a dense, triangular CW signal and an E-wave-dominant inflow support it.
• Integrate several signs: no single measurement grades MR on its own.

Pitfalls

• Check the atrial septum and the outflow tract for associated congenital lesions.
• Eccentric, wall-hugging jets look smaller than they are by colour area (the Coanda effect): rely on the vena contracta, the flow convergence and the other signs.

In the simulator every case varies the anatomy, the jets and the measurements: watch the lesion in Learn, then grade new cases in Practice and compare your answer with the exact one.

Related

Leaflet perforation · Endocarditis

Educational simulation to use under the supervision of a clinical tutor — not for clinical use.