Valve Analysis: “The Functional Classification”

FROM THE “BABEL SYNDROME” TO THE “PATHOPHYSIOLOGICAL TRIAD”

In Genesis, the Bible tells us that when the people building the Tower of Babel ceased to speak the same language, they could not work together anymore. Yet the “ Babel syndrome ” ^*

* See Glossary .

often prevails in medicine when different terms are introduced by different specialists to define similar findings. A sterling example of this is found in the multiple terminologies used to describe mitral valve pathology. Terms such as prolapse, flail, partial flail, redundant, overshooting, stretching, elongation, floppy, billowing, ballooning, Barlow, dysplasia, myxoid, and myxomatous, for example, have different meanings for different specialists. The confusion comes first from the fact that several of these terms are synonyms. For example, flail leaflet, overshooting leaflet, and leaflet prolapse are synonyms. Other synonyms are Barlow, billowing, ballooning, myxomatous valve, and mitral valve prolapse. Another source of confusion comes from the fact that for some specialists a given term such as “prolapse” means a dysfunction (leaflet prolapse) while for others it refers to a disease (mitral valve prolapse). The same chaotic situation applies to the term “floppy valve,” which is used to define either a valve morphology, or a dysfunction, or a disease. Similar confusion exists in tricuspid and aortic valve diseases, in which many of the previously listed terms are used without clear distinction. If surgeons and cardiologists do not speak the same language, how can they work together, proceed to a comprehensive valve analysis, and present valuable clinical data? These difficulties emphasize a pressing need to define precisely terminology in valve pathology.

A clarification can be obtained by using a pathophysiological triad with a sound distinction between the terms describing valve etiology (i.e., the cause of the disease), valve lesions resulting from the disease, and valve dysfunction resulting from the lesions ( Table 2-1 ).

Classifying terms into these three groups permits selection of one single term among several synonyms. Taking as an example the case of degenerative mitral valve diseases, Table 2-2 outlines our selection based on historical, scientific, and semantic considerations.

The pathophysiological triad facilitates communication between cardiologists, echocardiographers, and surgeons and greatly clarifies clinical investigations. In addition, it has significant clinical relevance for the individual patient because “long-term prognosis depends upon etiology, repair strategy depends upon dysfunction, and surgical techniques depend upon lesions.”