The Embryonic story of Mr. Aortic and Ms Mitral

Ashley Davidoff

The attraction of Mr. Aortic to Ms Mitral

goes back a long long way

As far back as fetal times ?

and in fact even beyond in evolution

Aorta and Pulmonary Artery Side by Side with Bilateral Caonus
Ashley Davidoff MD 2018
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When the valve of Mr. Aortic eyed the developing Miss Mitral

He knew from that moment and on

That she was to be his bride

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And that no other would come between them

He had to leave his fetal home above the right ventricle

A throne shared with his twin Miss Pulmonary

And he knew that they would now move in different circles

Each to go their own way

Miss Pulmonary with her chosen right ventricle while

He and Ms Mitral with the Left ventricle

Immediate Attraction
Mr Aorta only has eyes for Ms Mitral
How is Mr Aorta going to reach her?
Double Outlet RV Morphology
Ashley Davidoff MD 2018
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His mission was unrelenting

As he continued down on his trip

Her anterior leaflet was his goal

As he flapped to the Lub of his master.

 

He did have  a chance with her twin Ms Tricuspid

She was pretty too

But Miss Mitral was the twinkle of his eye

Since her flap was in synch with his

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 Resorption of the subaortic conus brings Mr Aorta (the aortic valve) toward Ms Mitral (the mitral valve)
Ashley Davidoff MD 2018
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And on a glorious day one summer

They bonded in fibrous union

In ecstasy they danced together

And never could be parted

Aortic Valve and Mitral Valve Bond in Fibrous Union
Ashley Davidoff MD 2018
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From then on they  lived their life

In a beautiful pulsatile glory

She gave him all that she received

and he in turn delivered

Mitral Valve and Aortic Valve Working Together to Keep Flow Moving Forward
Ashley Davidoff MD 2018
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Working Together to Form an Inflow and an Outflow to teh Left Ventricle
The mitral valve participates in the inflow as well as the outflow of the LV.
The LV does not have an infundibular chamber like the RV.
It is the anterior leaflet of the MV that has this dual function.
The first drawing represents LV diastole, showing the open anterior leaflet acting as the anterior, medial and rightward border of the inflow to the LV.
The second drawing is the systolic phase where this same anterior leaflet acts as the leftward and lateral border of the outflow tract.
Ashley Davidoff MD 2018
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And through many years they worked hard in harmony

Toward a greater strength for the whole

Together they produced

One million beats and a volume of enormous score

Nothing could separate this bonded union

?cept the disease that wreaked its havoc

And in the end the disease of  him

affected her greatly too

IHSS
Left Ventricular Muscular Obstruction with Mitral Regurgitation
This angiogram in RAO projection shows a hypercontractile left ventricle that has a ballet shoe appearance, with mitral regurgitation filling the left atrium.
The drawing shows the significant LVH small cavity of the LV, the area of subaortic muscle bundle (green) and the mitral regurgitation caused by the systolic anterior motion of the mitral valve.
Ashley Davidoff MD 2018
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Prolapse of the Mitral Valve and Aortic Regurgitation – Marfan’s Syndrome
This angiogram in RAO projection shows prolapse of both the anterior and posterior leaflets of the mitral valve with mitral regurgitation. Note also the bulbous appearance of the aortic sinuses. The back wall of the left atrium is flattened against the spine suggesting a narrow A-P diameter or pectus excavatum. These findings are characteristic of Marfan’s syndrome
Ashley Davidoff MD 2018
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Aged and happy they so declined

Still beating to the same drum

And they were of course happily assured

That their beat would repeat ? in the next of kin