Heart is a vital organ of circulatory system. Valves maintain the unidirectional fl ow of blood. Mitral valve (MV) prevents the backfl ow of blood into the left atrium. For the proper functioning of the heart, all valves should be intact. MV prolapse and regurgitation is the main cause of MV replacement. Mean circumference of MV varies from person to person. Aim of the present study is to measure the average size of the valve in the cadavers of North Karnataka region by using cardiac sizer, which would help in the selection of prosthetic valve in the cardiac surgery. Materials and Methods: This study was carried out on 50 cadaveric adult human hearts. Left atrium was opened along the left border of heart so as to expose the mitral orifi ce. Then, the diameter of the valve was measured by using cardiac sizer, whereas circumference was calculated manually. Number of mitral valve cusps and papillary muscles were observed. Results: The mean annular circumference and diameter of the mitral valve was found to be 8.03 ± 0.82 cm and 2.56 ± 0.32 cm, respectively. Majority (72%) of the mitral valves had the circumference ranging from 7.53 to 8.47 cm and the diameter ranging from 2.4 to 2.7 cm. Conclusion: The size of mitral valve in the North Karnataka region was found to be less as compared to the other studies. This study might help cardio-thoracic surgeon as well the prosthetic valve manufacturing companies for the rough estimation of the mitral valve size.

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Original Article
Mitral valve size measurement in North Karnataka
by using cardiac sizer: A cadaveric study
Kapil Amgain1, Sujit Kumar Thakur1, Rajendrakumar Dundappa Virupaxi2, Daksha Dixit3,
Suresh Pitambarappa Desai4, Mohan Gan5
1
Post Graduate Student, 2Associate Professor, 3Professor and Head of Department of Anatomy, 4Professor of Anatomy, 5Professor of
Cardiothoracic Surgery, Jawaharlal Nehru Medical College, KLE University, Belgaum, Karnataka, India
ABSTRACT
Background: Heart is a vital organ of circulatory system. Valves maintain the unidirectional flow of blood. Mitral valve (MV) prevents
the backflow of blood into the left atrium. For the proper functioning of the heart, all valves should be intact. MV prolapse and
regurgitation is the main cause of MV replacement. Mean circumference of MV varies from person to person. Aim of the present
study is to measure the average size of the valve in the cadavers of North Karnataka region by using cardiac sizer, which would help
in the selection of prosthetic valve in the cardiac surgery. Materials and Methods: This study was carried out on 50 cadaveric adult
human hearts. Left atrium was opened along the left border of heart so as to expose the mitral orifice. Then, the diameter of the valve
was measured by using cardiac sizer, whereas circumference was calculated manually. Number of mitral valve cusps and papillary
muscles were observed. Results: The mean annular circumference and diameter of the mitral valve was found to be 8.03 ± 0.82 cm
and 2.56 ± 0.32 cm, respectively. Majority (72%) of the mitral valves had the circumference ranging from 7.53 to 8.47 cm and the
diameter ranging from 2.4 to 2.7 cm. Conclusion: The size of mitral valve in the North Karnataka region was found to be less as
compared to the other studies. This study might help cardio-thoracic surgeon as well the prosthetic valve manufacturing companies
for the rough estimation of the mitral valve size.
Key words: Circumference of valve, cardiac sizer, diameter of valve, mitral valve
Introduction
Heart is a vital organ of circulatory system. Valves maintain
the unidirectional flow of blood. Mitral valve (MV) prevents
the backflow of blood into the left atrium. For the proper
functioning of the heart, all valves should be intact. It consists
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DOI:
10.4103/2321-4848.123016
of an orifice and its associated annulus, the cusp, the supporting
chordae tendineae, and papillary muscles.[1] Mechanical
support is provided by fibro elastic cardiac skeleton. The mean
circumference of mitral valve is 9.0 cm in males and 7.2 cm
in females.[2] The annulus changes its shape and dimension
during cardiac cycle also.[1] So, the aim of the present study is to
measure the mitral valve size in formalin-fixed cadaveric hearts.
Various heart diseases affect the valves causing stenosis,
regurgitation or prolapse of leaflets resulting valve insufficiency.
Such cardiac diseases requires repair of the valve and when
damage of the valve is more due to disease pathology, valve
replacement surgery will be attempted with the artificial valve.[3]
Artificial valve [Figure 1] may be of two types: 1) Biological
or Tissue Valve 2) Mechanical or Metal Valve.[4] Tissue valve
Corresponding Author:
Dr. Kapil Amgain, Department of Anatomy, Jawaharlal Nehru Medical College, KLE University, Nehru Nagar, Belgaum - 590 010,
Karnataka, India. E-mail: dr.kapilamgain@gmail.com
Archives of Medicine and Health Sciences / Jul-Dec 2013 / Vol 1 | Issue 2
105

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Amgain, et al.: Mitral valve size measurement in North Karnataka by using cardiac sizer
again is of two three types 1) Homograft (allograft), 2)
Autograft, 3) Heterograft (Xenograft). Homograft means
transplanting the human cadaveric heart valves in the
patient. In autograft patients, own body’s facia lata or
pericardium is taken and transplanted in the diseased
valve. In case of heterograft, bovine pericardial tissue is
taken and transplanted in the diseased person.[5] Mechanical
valve are made up of 1) Alloys of stainless steel, 2) Alloys
of molybedenum, 3) Pyrolytic Carbon, 4) Silicon, 5) Teflon,
6) Polyester etc.[6] The exact anatomy and measurement
of valve are needed for the better selection of prosthetic
heart valve.[4]
During mitral valve replacement surgery, surgeons need
actual circumference and diameter of the patient’s mitral
valve rather than the other details of anatomy of the valve.
Many publications dealing with the detailed anatomy are
found in literature, but most of them lack the numerical
values that were actually needed by the surgeons. So, this
study was aimed to measure the size of mitral valve by using
the cardiac sizer (which is used by cardiac surgeons) rather
than using the measuring tape or vernier calipers. Data of the
present study will be helpful to surgeons, anatomist as well
as for the prosthetic valve manufacturing company. During
mitral valve replacement, the surgeons use the cardiac sizer
[Figure 2] to measure the diameter of mitral valve in situ.
Accordingly, they choose the size of prosthetic mitral valve
for that patient and replace it. So, we also used the cardiac
sizer to measure size of mitral valve of the cadaveric heart
to know what type and size of prosthetic valve would fit for
the population of North-Karnataka.
Since there is variation in measurement of annular
diameter and circumference of mitral valve in different
studies and lack of similar data of North-Karnataka region,
the present study was undertaken for the measurement of
size of mitral valve. By considering the above mentioned
factors, we had attempted to study the size of mitral
valve by using the cardiac sizer for the measurements in
cadaveric hearts.
by using the formula (C = d). Photographs were taken
wherever necessary. Data analysis was done by using the
software (SPSS version 20). The results were disseminated
in tabular as well as narrative form after analyzing the data
by using appropriate statistics.
Figure 1: Prosthetic valve
Figure 2: Cardiac sizer
Figure 3: Measurement of mitral valve by cardiac sizer
Materials and Methods
A total of 50 adult human hearts without any obvious
pathology were obtained from the Department of Anatomy,
Jawaharlal Nehru Medical College, Belgaum; then, it was
numbered and preserved in 10% formalin solution. These
hearts were dissected carefully to visualize the cusps of
mitral valve. Diameter of the mitral valve was measured
by using the appropriate cardiac sizer after exposure of
the of the mitral valve by dissection of left atrial walls
[Figure 3], and circumference was calculated manually
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Amgain, et al.: Mitral valve size measurement in North Karnataka by using cardiac sizer
Results
In the present study, annular circumference of mitral valve
was found to range from 6.59 to 10.36 cm. Out of 50
cadaveric hearts (irrespective of sex), only 2 (4%) hearts
had maximum annular circumference of 10.36 cm, whereas
3 (6%) of them had the minimum circumference of 6.59 cm.
Maximum 13 (26%) hearts had the mitral valve circumference
of 7.85 cm followed by 8.47 cm (24%) and then 7.53 cm
(22%). Majority (72%) of the hearts had the mitral valve
circumference ranging from 7.53 to 8.47 cm. Details about
the frequency distribution of the valve is shown in Table 1.
Similarly, diameter of mitral valve ranged from 2.1 to
3.3 cm. Twenty six percent of hearts had mitral valve diameter
of 2.5 cm followed by 2.3 cm in 20% hearts. Only 6% hearts
had the minimum diameter of 2.1 cm, and 2% hearts had the
maximum diameter of 3.3 cm. Majority of the hearts (72%) had
the mitral valve diameter ranging from 2.4 to 2.7 cm [Table 2].
The mean diameter of mitral valve was 2.56 cm and mean
circumference was 8.03 cm, while standard deviation
for mean and circumference was 0.32 cm and 0.82 cm,
respectively [Table 3].
Discussion
The anatomy of mitral valve has been described in many
textbooks, but most of them lack the data in relation
Table 1: Annular diameter and circumference of mitral valve
Sr. No.
Diameter (d) of
Calculated
Mitral valve (cm) circumference (cm)
(C=d)
1
2
3
4
5
6
7
8
9
Total hearts
2.1
2.2
2.3
2.4
2.5
2.7
2.9
3.1
3.3
Percentage (%)
3
2
2
11
13
12
3
3
1
50
6.59
6.90
7.22
7.53
7.85
8.47
9.10
9.73
10.36
Number of
specimen
6.0
4.0
4.0
22.0
26.0
24.0
6.0
6.0
2.0
100%
Table 2: Frequency distribution table of diameter and circumference
of mitral valve
Sr. No. Diameter (d) Calculated circumference (C)=d Frequency Percentage (%)
1
2
3
2.1-2.3 cm
2.5-2.7 cm
2.9-3.3 cm
6.59-7.22 cm
7.53-8.47 cm
9.10-10.36 cm
7
36
7
14
72
14
Table 3: Mean diameter and circumference of mitral valve
Sr.No. Parameters
1
2
Diameter of mitral valve
Circumference of mitral valve annulus
Mean±S.D. (cm) Range value (cm)
2.56±0.32
8.03±0.82
2.1 to 3.3
6.59 to 10.36
with mitral valve measurements. In the present study,
circumference of the valve was found to be ranging from 6.59
to 10.36 cm, and majority (72%) of the cases had the valve
circumference ranging from 7.53 to 8.47 cm. Similarly, the
diameter of the valve was found to be ranging from 2.1 to 3.3
cm, and the majority (72%) of the hearts had the diameter
ranging from 2.4 to 2.7 cm. The observations regarding
the mitral valve show variable findings depending upon the
method used in study.[7] The diameter and circumference
obtained in the present study differs from the previous
study[8-15] is shown in the Table 4.
We did’t find similar study measuring the size of mitral valve
by using the cardiac sizer in the literature. There are various
studies on valve size measurement by dissection method.
A study done by dissection method in Maharashtra showed
that the average circumference of mitral valve is 9.34 cm.[16]
But, in our present study, we found that average size of
mitral valve is only 8.03 ± 0.82 cm, which is less than the
study done in Maharashtra. Similarly, table 4 showed the
comparison of circumference and diameter of mitral valve
with various other studies.
Walmsley T.[7] in 1929 mentioned the mitral valve measurements.
Later on, it was done by Rusted IE et al.[8] in 1952. The
circumference of the mitral valve in the present study [Table 1]
was found to be less than the measurements reported by
Tetsuro Sakai[14] by dissection method and Ormiston[13] (1981)
by 2D echocardiographic method but significantly lesser than
findings of Louis A. Du Plessis[11] (1964) in fresh hearts and
Brock RC[9] (1952), Bulkley and Roberts[12] (1975), Rusted IE[8]
(1952), and Chiechi et al.[10] (1956) by using dissection method.
In present study, measurements of mitral valve annular
circumference fall in range of 7.53 - 8.47 cm, which constitute
72% of total hearts. Only 14% of hearts had the circumference
ranging from 9.10 to 10.36 cm [Table 2]. In present study,
annular circumference was observed to be less than previous
Table 4: Comparison of mitral valve size between previous study
and present study
Sr. No Name of author
Year Circumference Diameter Method of study
1
2
3
4
1952
1952
1956
1964
9.9
10.05
10.00
10.10
2.5
3.20
3.18
3.21
1975
1981
1990
1999
2009
2012
2013
9.00
9.30
9.33
9.33
8.248
9.12
8.03±0.82
2.86
2.96
2.97±0.35
2.23
—
2.22
2.56±0.32
5
6
7
8
9
10
11
Archives of Medicine and Health Sciences / Jul-Dec 2013 / Vol 1 | Issue 2
Rusted, I. E et al.[8]
Brock RC[9]
Chiechi et al.[10]
Louis A
and Du Plessis[11]
Bulkley and Roberts[12]
Ormiston JA[13]
Tetsuro Sakai[14]
Sakai T[15]
Patil et al.[17]
Gunnal et al.[18]
Present study
Dissection method
Dissection method
Dissection method
Dissection method
Dissection method
2D echocardiography
Dissection method
Dissection method
Dissection method
Dissection method
Cardiac sizer
after dissecting
107

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Amgain, et al.: Mitral valve size measurement in North Karnataka by using cardiac sizer
observations given by different authors.[8-15,17] Louis in 1964
stated data of the dimensions of the valve, which may be of
interest to anatomists and surgeons.[11] Normal measurements
of the component parts of the mitral valve will help the surgeon
to assess the exact mechanical reason for valve insufficiency.
Vander Spuy[19] in 1964 found that the detailed anatomical
and functional features are essential in the manufacture of
an entirely anatomical whole mitral valve from autogenous
tissues. The data assessed in the present study can be used
for manufacturing mitral valves. From the observational study,
we found that mitral valve complex has two cusps, among
which anterior one is triangular and posterior is quadrangular
in shape. Posterior leaflet had two papillary muscles, whereas
anterior has only one. And, the papillary muscle of posterior
cusps is larger than the anterior one, which is found to be
similar with the study done by Muresian H et al.[20]
7.
8.
9.
10.
11.
12.
13.
14.
Conclusion
The size of mitral valve in the North Karnataka region was
found to be less as compared to the other studies. This study
might help cardio-thoracic surgeon as well the prosthetic
valve manufacturing companies for the rough estimation of
the mitral valve size.
15.
16.
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How to cite this article: Amgain K, Thakur SK, Virupaxi RD, Dixit D, Desai
SP, Gan M. Mitral valve size measurement in North Karnataka by using
cardiac sizer: A cadaveric study. Arch Med Health Sci 2013;1:105-8.
Source of Support: Nil, Conflict of Interest: None declared.
Archives of Medicine and Health Sciences / Jul-Dec 2013 / Vol 1 | Issue 2