Thorax (1964), 19, 221

The anatomy of the mitral valve and its

associated structures
LOUIS A. DU PLESSIS AND PAUL MARCHAND
From the Cardio-vascular Research Unit, Department of Thoracic Surgery,
University of Witwatersrand, Johannesburg

Since the development of mitral valve surgery the single plane by dividing its ring at the lateral
previously conventional descriptions of the valve commissure and by half splitting the medial papil-
have been reappraised, and many publications lary muscle mass. The opened-out valves were
have appeared dealing with its detailed anatomy then pinned to cork boards during fixation in
(Davila and Palmer, 1962; Bailey, Zimmerman, formalin and were finally waxed with diglycerol
and Likoff, 1960; van der Spuy, 1958; Morris, stearate.
1960; Frater and Ellis, 1961 ; Rusted, Scheifley, Measurements were made with point dividers
and Edwards, 1952; Harken, Ellis, Ware, and and an ordinary metric ruler. To determine the
Norman, 1948; Brock, 1952; and Gould, 1953). surface areas, the leaflets were traced on graph
Open-heart operations for correction of mitral paper and the enclosed squares were counted.
incompetence and for treatment of the grossly
diseased stenosed valve are becoming common- ANATOMY
place, and the results of valve replacement are
now promising. This advance is in part due to Various names have been given to the leaflet of
the surgeon's improved anatomical knowledge, but the mitral valve that is related to the aorta. It
some details of the structural relations of the valve has been called the aortic, the septal, the ventral,
are not widely known, and there is still a need for the antero-medial or the anterior leaflet. Multiple
standardization of terminology. An effort is made names have also been given to the commissures
in this paper to systematize the description of this and papillary muscles. The terminology we sug-
complex valve and to orientate it in relation to the gest, whilst neither original nor absolutely precise,
surrounding structures that must be avoided at is simple and descriptive. Figure 1 shows the four
operation. We also present data of the dimensions valves orientated to the saggital plane of the body.
of the valve, which may be of interest to ana- The mitral leaflet nearest the aortic valve is the
tomists and surgeons. Familiarity with the normal anterior leaflet, and the one opposite is the
measurements of the component parts of the valve posterior leaflet. The commissure pointing towards
will, at operation, help the surgeon to assess the the mid-line is the medial, and the one opposite is
exact mechanical reason for valve insufficiency. the lateral. The papillary muscles, being related
to the commissures, are also referred to as medial
MATERIALS AND METHODS and lateral.
The fibrous skeleton of the heart provides the
The following descriptions are based upon ob- key to understanding the anatomical relationships
servations made during intra-cardiac operations of the mitral valve. Its keystone is the aortic root,
and dissections of fresh human hearts which were which is the extension of the aorta below the
later preserved in diglycerol stearate by the aortic valves, and is the thickest most rigid part
method described by Kramer (1938). These of the skeleton. Fibrous extensions from the aortic
specimens, if correctly prepared, retain their true root form the scaffold for the pulmonary,
features and relationships and can be conveniently tricuspid, and mitral rings. Figure 2 is a diagram
studied or used for teaching purposes. of the fibrous skeleton based on Fig. 3, which
The dimensions of the valve were taken from shows the dissected aortic root and fibrous skele-
10 normal hearts. The mitral leaflets with the ton. At the base of the non-coronary cusp, the
annulus, chordae, and papillary muscles were aortic root is continuous with the interventricular
removed, and the valve was flattened out in a septum, and its downward extension forms the
221
222

FIG. 1.
Pulmonary valve

Mitral valve
valve
Mitral
Anterior

|
Posterior
Louis A. du Plessis and Paul Marchand

Aortic valve

Tricuspid valve

The four valves of the heart orientated to the

saggital plane of the body. The mitral valve nearest the
aortic valve is the anterior leaflet, and the one opposite is
the posterior lea-flet. The commnissure pointing towards the
mid-line is the medial, and the one opposite is the lateral.

membranous septum. Immediately above the junc-

tion of the ventricular septum and the tricuspid
ring the aortic root is extremely thin, and this is
named the undefended area. Occasionally this
area is deficient, and blood will then shunt from
the left ventricle directly into the right atrium.
Posteriorly and to the left, the aortic root expands
into a broad membranous structure, the inter-
valvular space, to which the anterior third of the
mitral annulus attaches. The intervalvular space
therefore lies between the bases of the left and
non-coronary aortic cusps and the mitral annulus.
Posteriorly and to the right, the aortic root
thickens to form the right fibrous trigone which
separates the mitral and tricuspid rings and forms
the base of the inter-atrial septum. A tendinous
extension from the right fibrous trigone, the ten-
don of Todaro (Grant, 1958), extends between the
layers of the inter-atrial septum. On the left side
the aortic root again thickens to form the left
fibrous trigone. This trigone is closely related to
the left coronary artery and forms part of the base
of the transverse sinus of the heart.
The pulmonary valve ring is anterior and to the
left of the aortic valve ring. It is set in a plane
almost at right angles to that of the aortic valve
and is attached to the base of the aorta by a
monary
right

FIG. 2.
valve ring
ventricle supported
andis the

intervaovular spac

Mitral ring
Tendon of To

)
/
X-

aor
gf~ eptum
the tendon of the conus. The rest of the pul-
interventricular
The tricuspid and pulmonary valves occupy two
openings within the right ventricle separated by
a band of myocardium, the crista supraventri-

/
of the
by the baseseptum.

cularis. On the other hand, the mitral and aortic

valves share a common opening in the base of the
left ventricle (Fig. 4). Although the aortic and
mitral valves occupy the same opening in the myo-
cardium, they lie at an angle of 400 to each other
so that the anterior leaflet of the mitral valve
forms a watershed between the inflow and outflow
streams of the left ventricle (Fig. 5).
Considerable controversy centres around the
exact position and even the existence of that part
of the mitral annulus related to the anterior leaflet.

l. fibrous trigone
root
Pulmonary root
~~~~~~~~~~~~~~~~~Aortic
g

R fibrous trigone

TriCUSDid rinq
Diagram of the fibrous skeletont of the heart.

FIG. 3. Dissected aortic root andfibrous skeleton of the

*

heart. The valve leaflets andpart of the left ventricle have

Undefended space
Membranous

flimsy fibrous extension of the aortic root called been retained.

 The anatomy of the mitral valve and its associated structures 223
Combined Pulmonary that the hinge is formed by the common fibrous
aortic and mitral valve origins of the postero-lateral half of the aortic
opening
root, of the antero-medial mitral leaflet and the
major part of two aortic cusps'. Bailey et al. (1960)
maintain that this part of the mitral ring is defi-
cient. They describe the annulus as a horseshoe-
shaped fibrous thickening of the upper edge of the
left ventricular myocardium, which extends from
the right fibrous trigone around to the left fibrous
trigone and is deficient antero-medially. These
three opinions are really different ways of saying
the same thing namely, that the anterior leaflet
shares a common origin with parts of two aortic
cusps. We do not agree with this view.
It is convenient to describe the mitral ring by
dividing it into an anterior third, to which the base
of the anterior leaflet is attached and a posterior
FIG.4. Diagram to show that the tricuspid andpulmonaty two-thirds, from which the posterior leaflet arises.
valves occupy separate openings within the right ventricle The posterior two-thirds of the ring is a fibrous
whereas the mitral and aortic valves share a common
opening in the base of the left ventricle. thickening at the base of the left ventricle extend-
ing from the right to the left fibrous trigone. The
anterior third of the mitral ring is closely related
to the aortic root. It is a well-defined fibrous cord
extending from the one trigone to the other and
into which the base of the left atrium also inserts
(Figs. 6, 7, and 8). The part of the aortic root
enclosed by the mitral annulus and the bases of
the left and non-coronary leaflets of the aortic
valves is the intervalvular space. We do not believe
that this space can be described as part of the
mitral valve because it lies above the hinge of
the anterior leaflet (point y of Fig. 8). According
to van der Spuy's contention, point x in Fig. 8,
i.e., at the bases of the aortic leaflets, is the hinge
of the anterior leaflet. However, the left atrial
muscle attaches at point y, and during atrial con-
traction this point is drawn inwards whilst the
leaflet flaps open, so that the intervalvular space
does not move with the mitral curtain. The left
atrial attachment at must anchor the anterior
leaflet, which must therefore hinge here. We agree
with Brook (1952) that this is the mitral annulus.
FIG. 5. Diagram illustrating that the mitral and aortic It is a substantial structure which provides ade-
valves, although occupying the same opening in the left
ventricle, are set at an angle of 400 to each other. The quate bulk to hold the sutures of a prosthetic
anterior mitral leaflet thus forms a watershed between the ring.
left ventricular inflow and outflow streams. The mitral valve leaflets form a continuous veil
attached as a muff to the circumference of the
mitral ring. The free edge of this veil hangs into
Frater and Ellis (1961) state that the anterior the left ventricle and is split by indentations, none
leaflet of the mitral valve is attached to the base of which reaches to the mitral ring. The specimen
of the non-coronary and most of the base of the shown in Fig. 9 is representative of the average
left coronary cusp of the aortic valve. Van der valve. It shows the accentuated anterior part of
Spuy (1958) states that the anterior mitral leaflet the valve curtain which is attached to the anterior
'is a hinged extension into the cavity of the left third of the mitral annulus. The anterior leaflet
ventricle of the postero-lateral aortic root and is roughly triangular in shape. The base of the
 ._. _'
*F[;>'|gi_:kWOf.Xtb2,ns6;eB>I.E':!dlt=zF
224 Louis A. du Plessis and Paul Marchand

(L.l R.F.T.

Zi.'''- :-'"
Rh. .:
T4.....
B4
:

s
*XisL __

FIG. 6. Transilluminated opened-out mitral and aortic

valves seen from the ventricular aspect. Note (a) the two
aortic cusps are separated from the anterior mitral leaflet
(A.L.) by the intervalvular space (. V.S.); (b) the anterior
part of the mitral annulus extends between the two fibrous
trigones (L.F. T. and R.F. T.); (c) the central portion of the
anterior mitral leaflet is free of chordal attachments.
Chordae tendineae are attached to the whole ventricular
surface of the posterior leaflet; (d) the angleformed by the
planes of the aortic and mitral valves is approximately FIG. 8. Diagram illustrating that the point of hinging of
40°; (e) the anterior part of the mitral annulus is half the the anterior mitral leaflet (y) corresponds to the attach-
length of its posterior portion; and (f) the depth of the ment of the base of the left atrium to the posterior aortic
anterior lea-flet is twice that of the posterior leaflet. root. This is the anterior part of the mitral annulus.

_ X s ' ~~~~~~~~~~~~~~~~~~~~~~~~~~~..-l..
;S§5_5>,t, q
v . .:t:. B=;iR^# 10 |

f., W-1K.: .:

FIG. 7. Splayed open mitral and aortic valves seen from FIG. 9. Splayed open mitral valve. Note (a) the triangular
the atrial surface of the mitral valve. Note that the anterior shape of the anterior leaflet and the rectangular shape of the
part of the mitral ring (A.M.R.) is a definite structure to posterior leaflet; (b) the mitral valve curtain is shortest at
which part of the base of the left atrium is attached. the fibrous trigones.

triangle is attached to the annulus, and the apex leaflet is smooth and flat but the ventricular sur-
is the free edge which is devoid of chordal attach- face is ridged by the insertion of chordae of the
ments. The two sides of the triangle give attach- second order which, however, spare the central
ment to chordae of the first order, and these are portion of the valve leaflet. The posterior leaflet
responsible for the scalloped appearance of the is roughly rectangular in shape, and its free edge
leaflet edge. The atrial surface of the anterior is usually more deeply scalloped than that of the
 The anatomy of the mitral valve and its associated structures 225

anterior leaflet. At the centre of its free edge

there is also a small area devoid of chordal attach-
ments. This site marks the separation between the
chordae rising from the two papillary muscles.
Unlike the anterior leaflet, the ventricular surface
of the posterior leaflet is covered with chordal
attachments. Apart from chordae of the first and
second order, chordae of the third order are
attached to this surface (Brock, 1952).
The valve curtain is shortest near the two points
of attachment of the mitral annulus to the left
and right fibrous trigones. This is the junctional
area between the anterior and posterior leaflets. In
some specimens (Fig. 10) the scallops in the free .7--
..r'
.>,I.w
edge of the ventricular curtain may be exagger- -LzL.
0
cc,c"Cly 5 r"5
ated and may nearly reach the annulus to give L , c. r-'- -,-. ---,
the appearance of separate leaflets, called acces- FIG. 11. Diagram illustrating the structures related to the
sory leaflets by some authors (Chiechi, Lees, and mitral valve annulus which must be avoided during insertion
Thompson, 1956). In rare cases the scallops in of the prosthetic valve.
the junctional area are so deep that they reach the
annulus, and mitral regurgitation results. (2) Coronary vessels. Where the lateral com-
missure abuts against the left fibrous trigone, the
great cardiac vein and the circumflex branch of
the left coronary artery are endangered by deep
sutures.
-.- ima Rol... -gala (3) Bundle of His. Where the medial commissure
meets the right fibrous trigone the atrio-ventricular
bundle may be injured.
(4) The coronary sinus. The opening of the
; ... .'. coronary sinus into the right atrium is slightly
behind the site of the atrio-ventricular bundle.
Along the posterior two-thirds of the mitral
annulus the coronary sinus and left coronary vein
may be incorporated in careless suturing.
The annulus provides sufficient strong fibrous
tissue in which to place sutures for anchoring a
prosthetic valve ring. Good exposure and careful
suturing will avoid damage to related structures.
FIG. 10. Ventricular aspect of the mitral valve. Note that
exaggerated scalloping in the mitral valve curtain (A andB) DIMENSIONAL DATA
can give the appearance of a separate commissural leaflet,
sometimes called accessory leaflets.
Table I lists the dimensions of the annulus and
of the leaflet depth of 10 normal valves. It will
OTHER STRUCTURES RELATED TO THE MITRAL VALVE be seen that the length of the annular attachment
ANNULUS Figure 11 shows four important struc- of the anterior leaflet is half that of the posterior
tures related to the annulus which have to be leaflet. The maximum depth of the anterior leaflet,
avoided during replacement of the prosthetic measured from its annular attachment to its apex,
valve. These are: is approximately twice that of the posterior leaflet.
(1) The intervalvular space (Figs. 6 and 7). This In rheumatic fever the inflammatory process and
space affords a certain margin of safety when the subsequent fibrosis is very often concentrated
inserting a prosthetic valve, but, even so, carelessly at the free edges of the valve leaflets, particularly
placed sutures may transfix the bases of the left at the points of insertion of the chordae tendineae.
and non-coronary aortic cusps and cause aortic As the depth of the posterior leaflet is half that
insufficiency. of the anterior leaflet, equivalent contraction of
226 Louis A. du Plessis and Paul Marchand
TABLE I surface area of the mitral annulus. In the cada-
veric heart, the surface area of the valve orifice is
Length of Annular Maximal Length of therefore four-fifths that of the combined leaflet
Specimen Attachment ofLeaflet(cm.) Leaflet (cm.)
No. area. In addition, in life the mitral valve orifice
Anterior Posterior Anterior Posterior
narrows during ventricular systole so further
1
2
39
30
7-2
6-4
2-8
2-2
1-8
1.0 reducing its surface area and leaving relatively
3 39 6-7 2-6 1-4 even more valve leaflet surface available to close
4 3-2 6-4 3-2 1-2
5 2-9 6-9 25 1-3 the atrio-ventricular orifice. The normal mitral
6 3-1 54 2-4 1-2 valve thus closes not only by marginal contact but
7 3-4 5 1 25 1-3
8 4 1 8-7 29 1-4 by liberal leaflet surface apposition. This is an
9 4.5 7.9 30 1.5
10 3-2 6-0 2-6 1-3 important concept in the recognition of the
Averages 35 6-7 2-7 13 mechanisms causing mitral regurgitation where
leaflet shortening, leaflet rigidity, or dilatation of
the mitral annulus are present.
the scar tissue in both leaflets will adversely affect
the function of the posterior leaflet before that of
the anterior leaflet. This explains why shortening
of the posterior leaflet is the most common cause
of rheumatic mitral regurgitation.
The mitral valve ring is on average 1 1 cm.
longer than the free edge of the valve curtain
(Table II). This is the reason why the mitral valve
is conical in shape with a larger inlet than outlet.
As the anterior and posterior leaflets are not
equally deep, the plane of the outlet orifice does
not correspond with that of the annulus. To some
extent this compensates for the smaller size of the
' ,1~~ ~ ~'
..l
...

outlet orifice (Fig. 12). Although the anterior and

posterior leaflets differ in shape, annular attach- FIG. 12. Diagram showing the conical shape of the mitral
ments, and depth, their individual surface areas valve. Because the anterior part of the valve curtain is
are approximately equal (Table II). The mitral deeper than the posterior, the outlet orifice lies at an
annulus is not a perfect circle and its surface area oblique plane to the inlet (see text).
can only be estimated approximately. The average
length of the mitral ring in the 10 specimens SUMMARY
examined was 10-2 cm., and from this the average
surface area is calculated to be 8-1 cm.2 The aver-
age surface area of the anterior leaflets was Standardization is sought for the nomenclature of
4*9 cm.2 and of the posterior leaflets 5 cm.2 (Table the mitral valve leaflets, commissures, and papil-
II). The average surface area of both leaflets lary muscles. We offer support for the use of the
therefore is 10 cm.2, which is greater than the terms 'anterior' and 'posterior' for the leaflets and
'lateral' and 'medial' for the commissures. As the
papillary muscles are related to the commissures
TABLE II they should also be referred to as 'lateral' and
medial'.
Total Length of Surface Area of
Specimen Length of Free Edge of Leaflet (cm.) The fibrous skeleton of the heart is described
No. Valve Ring Valve with particular reference to its relation to the
(cm.) Curtain(cm.) Anterior Posterior
anterior part of the mitral valve annulus.
111 10 5 5-2 5-3
2 94 8-5 4-0 4-5 The shape, chordal attachments, and inlet and
3 10-6 95 5-5 4-8 outlet orifices of the mitral valve curtain are
4 9-6 8-5 4-5 4-8
5 9-8
8-5
8-4
8-0
4-3
4-4
4-6
4-5
described. The mitral valve is a continuous veil
6
7 8-5 79 4-5 4-2 of tissue, but indentations at the fibrous trigones
8 12-8 11-7 5*9 6-5 divide it into a triangular anterior and rectangular
9 12 4 93 5-6 5-8
10 9-2 8-3 50 5-0 posterior leaflet. The central part of the ventri-
Averages 10-2 9 1 49 50 cular surface of the anterior leaflet is free from
chordal attachments, whereas the whole of the
 The anatomy of the mitral valve and its associated structures 227

corresponding surface of the posterior leaflet gives Some of the diagrams were drawn by the staff of
attachment to chordae tendineae. the National Institutes of Health, Bethesda 14, Mary-
The mitral valve inlet is larger than its outlet, land, U.S.A. We wish to thank Dr. Andrew G.
but an oblique setting of the plane of the outlet Morrow for granting us these facilities.
orifice to some extent compensates for the
discrepancy in size. REFERENCES
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