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Mitral leaflet perforation on echocardiography

What to look for: Normal coaptation; the jet goes through a leaflet.

Key findings

• A perforation is a hole in the body of a leaflet: the leaflets coapt normally (type I) and the jet passes through the leaflet, away from the coaptation line.
• It is usually caused by endocarditis: look for vegetations on this valve and on the aortic valve.
• In aortic valve endocarditis the regurgitant jet can seed the anterior mitral leaflet, causing a leaflet aneurysm or perforation.

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

• A jet through a perforation is easy to take for an ordinary jet at the coaptation line: follow it back to its origin in parasternal short axis, or with TOE and 3D.

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

Endocarditis · Cleft of the anterior leaflet

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