Carpentiers Surgical Classification of Mitral Valve Pathology

This is a surgical classification of mitral leaflet pathology initially described by Carpentier in

1983 in his seminal paper: Cardiac Valve Surgery---the French Correction, and later modified
by him in 1995 to include Type IIIb as a mechanism of leaflet restriction during systole causing
regurgitation.

The classification is as follows:

Type I: Normal Leaflet Motion
Annular dilation
Leaflet perforation
Type II: Leaflet Prolapse
Chordal Rupture
Chordal Elongation
Papillary muscle rupture
Papillary muscle
elongation

Figure 1

Type III: Restricted Leaflet Motion

Type IIIa: During diastole
Type IIIb: During systole

The Carpentier classification is defined surgically as follows. The mitral valve leaflet posterior
scallops are identified as P1 (anterior scallop), P2 (middle scallop), and P3 (posterior scallop) as
viewed by the surgeon though a left atriotomy. The three corresponding segments of the anterior
leaflet are termed A1 (anterior part), A2 (middle part), and A3 (posterior part). The remaining
two segments are the anterior commissure (Ac) and posterior commissure (Pc).
The regions of the mitral valve leaflets are defined surgically through a left atriotomy by taking
nerve hooks and lifting each posterior leaflet scallop and their corresponding, coapting anterior
leaflet. The posterior leaflet P1 scallop coapts with A1. The posterior leaflet P2 scallop coapts
with A2. The posterior leaflet P3 scallop coapts with A3. Surgical pathology was then defined
by leaflet section: P1/A1, P2/A2, P3/A3. (Functionally this is what we do today using
echocardiography).
For example, a type II, A3 P3 indicates a prolapse (type II) of both the posterior scallop (P3) and
the corresponding posterior part of the anterior leaflet (A3), two prolapses that must be corrected.
A combined type II A2, Type IIIa P3 indicates a localized prolapse (type II) of the middle
portion of the anterior leaflet (A2) associated with a restricted opening (type IIIa) of the posterior
scallop (P3).

When the ASE/SCA developed their echocardiographic terminology for mitral valve leaflets the
Carpentier terminology of mitral valve leaflet scallops was adopted.
Understanding of papillary musclechordal leaflet scallop relationship is imperative. This has
been defined anatomically by Lam et al. The anatomical review in this handout attempts to
provide these relationships as they relate to the Carpentier classification.
In defining this classification, Carpentier also differentiated between types of leaflet prolapse:
prolapsed leaflet, billowing valve (Barlow), and billowing valve plus prolapse leaflet (Figure 2).
This and Carpentiers reference to the gross description of mitral valve pathology as either
Barlows Disease or Fibroelastic Deficiency has led to the use of these terms as gross descriptors
of mitral valve leaflet appearance ( see section on mitral valve pathologic terminology).

Figure 2

The diagnosis of mitral valve prolapse has been given to those people that on auscultation have
a midsystolic click. The term Barlows Syndrome refers to the syndrome of a midsystolic click
and systolic murmur. Adams reviews the history of the terminology nicely. Note that
Carpentiers definition of a billowing valve (Barlow) would on physical exam exhibit a
midsystolic click. The billowing valve and prolapse would give a midsystolic click and
regurgitant murmur.

References:
1) Carpentier A, et al: Reconstructive Surgery of Mitral Valve Incompetence. Ten-Year
Appraisal. J Thorac Cardiovasc Surgery 1980;79:338-348.
2) Carpentier A: Cardiac Valve Surgerythe French Correction. J Thorac Cardiovasc
Surg 86:323-337,1983.
3) Fornes P, Carpentier A, et al: Correlation Between Clinical and Histologic Pattern of
Degenerative Mitral Insufficiency: A Histomorphometric Study of 130 Excised
Segments. Cardiovasc Patho 1999;8:81-92.
4) Carpentier A, et al: the Physio-Ring: An Advanced concept in Mitral Valve
Annuloplasty. Ann Thorac Surg1995;60:1177-86.
5) Brunberger E, Carpentier A, et al: Very long Term Results (More than 20 Years) of
Valve Repair With Carpentiers Technique in Nonrheumatic Mitral Valve Insufficiency.
Circulation. 2001;104(suppl I):I-8-I-11.
6) Lam JHC, Ranganathan N, Wigle ED, Silver MD. Morphology of the human heart
valve. I. Chordae Tendineae: A new classification. Circulation 41:449-58, 1970.
7) Lam JHC, Ranganathan N, Wigle ED, Silver MD. Morphology of the human mitral
valve. II. The valve leaflets. Circulation 41:459-67, 1970.