Article Text

Download PDFPDF
Anatomy of the mitral valve relative to controversies concerning the so-called annular disjunction
  1. Robert H Anderson1,
  2. Madalina Garbi2,
  3. Dasa Zugwitz3,4,
  4. Steffen E Petersen5,
  5. Robin Nijveldt6
  1. 1 Biosciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
  2. 2 Department of Cardiology, Royal Papworth Hospital, Cambridge University Health Partners, Cambridge, UK
  3. 3 Cardiovascular Surgery, University Medical Centre, Ljubljana, Slovenia
  4. 4 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
  5. 5 William Harvey Research Institute, Queen Mary University of London, London, UK
  6. 6 Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
  1. Correspondence to Professor Robert H Anderson, 60 Earlsfield Road, London SW18 3DN, UK; sejjran{at}


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.

  • echocardiography
  • diagnostic imaging
  • mitral valve insufficiency

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Twitter @MadalinaGarbi

  • Contributors The concept for the review was generated by RHA, who discussed the problems with SEP, RN and DZ. Collectively, they then collaborated with MG to ensure that echocardiographic details were correct. The authors then worked together to illustrate and produce the final draft as now submitted.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests SEP is an editorial board member of BMJ Heart.

  • Provenance and peer review Not commissioned; externally peer reviewed.

Linked Articles