Pathophysiology of the Mitral Valve

Tomasz A. Timek, MD, PhD, James I. Fann, MD

Historical Perspective

Detailed description of mitral valve anatomy based on laboratory dissection was introduced by Leonardo da Vinci at the beginning of the 16th century, thus paving the way for subsequent study of its form and function (Figure 1).However, investigations of the surgical treatment of mitral valve disease did not progress until 4 centuries later, beginning with Sir Brunton’s observations relating to the potential for operative relief of mitral stenosis in 1902.[1]The first successful partial resection of a stenotic mitral valve was performed by Cutler and Levine[2] in 1922, whereas mitral commissurotomy was introduced by Soutter in 1925.[3] It was not until the work of Harken and Bailey in the late 1940s with closed mitral commissurotomy that a more reliable operation was available.[4],[5] With introduction of cardiopulmonary bypass in 1953, direct visualization and surgery of the mitral valve became feasible. Braunwald performed the first mitral valve replacement in 1960, leading to the treatment for mitral valve disease not amenable to open commissurotomy [6][7] From the early days of mitral valve surgery, some surgeons attempted to repair and preserve the mitral valve,[8] continuing the pioneering efforts of Lillehei[9] in repairing rather than replacing the mitral valve. Notable are surgeons, such as Kay, Reed, Wooler, and others, who explored repair techniques for incompetent valves during this time.[10],[11],[12] In the early 1970s, Carpentier introduced a new classification system for mitral regurgitation and described operations for correcting leaflet abnormalities including annuloplasty. [13] Duran, Cosgrove, and others contributed to these repair techniques with the use of reduction ring annuloplasty.[14],[15] Minimally invasive mitral valve surgery and robotic mitral valve surgery have continued to evolve since the 1990s. [16],[17],[18] Additionally, percutaneous catheter-based mitral valve procedures are being employed with many more technologies in clinical trials. See Transcatheter Mitral Valve Repair chapter (G.12)[19],[20] The dynamic evolution of mitral valve procedures must continue to be rooted in detailed understanding of the intricate physiologic interplay of the mitral valve complex.

Figure 1
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Leonardo da Vinci’s drawings of the mitral valve based on anatomical dissection circa 1504.

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Last updated: January 28, 2023