Aortic-Mitral Coupling

  • Wendy Tsang
  • Karima AddetiaEmail author
  • Roberto M. Lang


The aortic and mitral valve share a common fibrous border call the aortic-mitral curtain. Due to this anatomic linkage, normal aortic and mitral valve function are interdependent demonstrating coupled reciprocal behavior. Thus, during the cardiac cycle when aortic annular area is at its maximum, mitral annular area is at its minimum and vice versa. Additionally, the angle between the aortic and mitral valves is smallest during left ventricular ejection. Overall, this annular area reciprocity and angulation likely play a role in the efficiency of the heart as a pump.

When isolated aortic valve stenosis is present, changes to the ‘unaffected’ mitral valve occurs resulting in small mitral annular areas and reduced mitral annular function. These changes persist even with surgical or percutaneous treatment of the aortic valve. In contrast, in patients with degenerative mitral valve disease, the aortic valve appears to remain unaffected. However, after mitral valve repair with an annuloplasty ring, aortic annular pulsatility is reduced, which could impact normal aortic root function. Overall, diseases affecting the aortic or mitral valves and interventions to treat these diseases should include assessment of the impact on both valves.


Aortic valve Mitral valve Aortic-mitral coupling 


  1. 1.
    Piazza N, de Jaegere P, Schultz C, Becker AE, Serruys PW, Anderson RH. Anatomy of the aortic valvar complex and its implications for transcatheter implantation of the aortic valve. Circ Cardiovasc Interv. 2008;1(1):74–81.CrossRefGoogle Scholar
  2. 2.
    Anderson RH. Clinical anatomy of the aortic root. Heart. 2000;84(6):670–3.CrossRefGoogle Scholar
  3. 3.
    Underwood MJ, El Khoury G, Deronck D, Glineur D, Dion R. The aortic root: structure, function, and surgical reconstruction. Heart. 2000;83(4):376–80.CrossRefGoogle Scholar
  4. 4.
    Berdajs D, Zund G, Camenisch C, Schurr U, Turina MI, Genoni M. Annulus fibrosus of the mitral valve: reality or myth. J Card Surg. 2007;22(5):406–9.CrossRefGoogle Scholar
  5. 5.
    Lansac E, Lim KH, Shomura Y, Goetz WA, Lim HS, Rice NT, et al. Dynamic balance of the aortomitral junction. J Thorac Cardiovasc Surg. 2002;123(5):911–8.CrossRefGoogle Scholar
  6. 6.
    Veronesi F, Corsi C, Sugeng L, Mor-Avi V, Caiani EG, Weinert L, et al. A study of functional anatomy of aortic-mitral valve coupling using 3D matrix transesophageal echocardiography. Circ Cardiovasc Imaging. 2009;2(1):24–31.CrossRefGoogle Scholar
  7. 7.
    Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(13):e1–142.CrossRefGoogle Scholar
  8. 8.
    Tsang W, Veronesi F, Sugeng L, Weinert L, Takeuchi M, Jeevanandam V, et al. Mitral valve dynamics in severe aortic stenosis before and after aortic valve replacement. J Am Soc Echocardiogr. 2013;26(6):606–14.CrossRefGoogle Scholar
  9. 9.
    Tsang W, Meineri M, Hahn RT, Veronesi F, Shah AP, Osten M, et al. A three-dimensional echocardiographic study on aortic-mitral coupling in transcatheter aortic valve replacement. Eur Heart J Cardiovasc Imaging. 2013;14(10):950–6.CrossRefGoogle Scholar
  10. 10.
    Mahmood F, Warraich HJ, Gorman JH 3rd, Gorman RC, Chen TH, Panzica P, et al. Changes in mitral annular geometry after aortic valve replacement: a three-dimensional transesophageal echocardiographic study. J Heart Valve Dis. 2012;21(6):696–701.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Vergnat M, Levack MM, Jackson BM, Bavaria JE, Herrmann HC, Cheung AT, et al. The effect of surgical and transcatheter aortic valve replacement on mitral annular anatomy. Ann Thorac Surg. 2013;95(2):614–9.CrossRefGoogle Scholar
  12. 12.
    Ruel M, Kapila V, Price J, Kulik A, Burwash IG, Mesana TG. Natural history and predictors of outcome in patients with concomitant functional mitral regurgitation at the time of aortic valve replacement. Circulation. 2006;114(1 Suppl):I541–6.PubMedGoogle Scholar
  13. 13.
    Timek T, Dagum P, Lai DT, Green GR, Glasson JR, Daughters GT, et al. The role of atrial contraction in mitral valve closure. J Heart Valve Dis. 2001;10(3):312–9.PubMedGoogle Scholar
  14. 14.
    Shibayama K, Harada K, Berdejo J, Mihara H, Tanaka J, Gurudevan SV, et al. Effect of transcatheter aortic valve replacement on the mitral valve apparatus and mitral regurgitation: real-time three-dimensional transesophageal echocardiography study. Circ Cardiovasc Imaging. 2014;7(2):344–51.CrossRefGoogle Scholar
  15. 15.
    Veronesi F, Corsi C, Sugeng L, Caiani EG, Weinert L, Mor-Avi V, et al. Quantification of mitral apparatus dynamics in functional and ischemic mitral regurgitation using real-time 3-dimensional echocardiography. J Am Soc Echocardiogr. 2008;21(4):347–54.CrossRefGoogle Scholar
  16. 16.
    Caimmi PP, Diterlizzi M, Grossini E, Kapetanakis EI, Gavinelli M, Carriero A, et al. Impact of prosthetic mitral rings on aortomitral apparatus function: a cardiac magnetic resonance imaging study. Ann Thorac Surg. 2009;88(3):740–4.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Cardiology, Department of MedicineUniversity of Toronto, Toronto General Hospital, University Health NetworkTorontoCanada
  2. 2.Section of Cardiology, Department of Medicine, Heart and Vascular CenterUniversity of Chicago MedicineChicagoUSA

Personalised recommendations