▪ MV chordae ▪ Identification of chordal elongation, rupture, chordal shortening, and fusion MV, Mitral valve The most commonly used functional classification of rheumatic MV disease is the Carpentier classification This classification is aimed at optimizing surgical repair strategies for mitral insufficiency and is detailed in Box 55.3.37 Box 55.3 Carpentier's Functional Classification of Mitral Valve Insufficiency Type I: Annular dilation with normal leaflet motion Type II: Leaflet prolapse Type IIa/IIIp: Prolapse of anterior mitral valve leaflet and restriction of posterior leaflet Type III: Restricted leaflet motion a, Anterior, p, posterior Aortic Valve Disease The early disease process is characterized by AR, which can be eccentric, with leaflet prolapse resulting in a loss of the height of the cusp tissue and commissures (Fig 55.9A–B).38 With time the leaflets thicken, retract, and their edges roll, giving rise to a mixed hemodynamic effect (stenosis and regurgitation, Fig 55.9C) Over the course of decades, calcification of leaflets occurs progressively and the pendulum swings toward a predominantly stenotic hemodynamic effect This is extremely rare in children and adolescents The key elements of AV assessment by echocardiography are listed in Box 55.4 FIG 55.9 Rheumatic heart disease of the aortic valve (A) Transesophageal echocardiogram (TEE) in a patient with mixed aortic and mitral valve disease View was obtained at 115 degrees and shows prolapse of the right coronary commissure There is thickening of the valve leaflet edge (B) TEE obtained at 56 degrees showing a short-axis view of the aortic valve The right coronary cusp has prolapsed, resulting in a central area of noncoaptation that results in aortic regurgitation (C) Parasternal long-axis view showing markedly thickened aortic valve involving both right and left coronary cusps Box 55.4 Key Elements in the Echocardiographic Assessment of Aortic Valve Anatomy ■ AV annulus ■ Measurement of diameter and comparison with normal z-score measurements ■ AV leaflets ■ Leaflet height ■ Identification and localization of leaflet prolapse ■ Assessment of leaflet thickening and calcification ■ Definition of mechanism of dysfunction