Flail vs Prolapse of leaflet on echocardiography

 Diagramatic difference between Flail and prolapse:

Key point 👉 

In prolapse tip of the leaflet is not evulsed into LA..only the leaflet body is protruding into LA, whereas in flail tip of the leaflet is hanging into LA due to ruptured chords.

🫀 Flail vs Prolapse Mitral Leaflet on Echocardiography — How to Differentiate?

Mitral valve (MV) abnormalities are common findings on echocardiography, and among these, leaflet prolapse and flail are crucial to recognize — both for accurate diagnosis and surgical planning. Though often mentioned together, they represent different severities of the same spectrum of mitral valve degeneration.

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🔍 1. Mitral Valve Prolapse (MVP) – The Basics

Definition:

Mitral valve prolapse refers to systolic displacement of one or both mitral leaflets >2 mm beyond the annular plane into the left atrium during systole.

Echocardiographic Features:

Seen best in parasternal long-axis and apical 3-chamber (A3C) views.

Leaflet tips remain coapting, though displaced into LA.

“Bow-shaped” or “systolic doming” appearance of leaflet.

Chordae are intact.

Usually associated with mild to moderate MR, often late-systolic and posteriorly directed (if posterior leaflet prolapse).

Clinical Context:

Seen in myxomatous degeneration, Barlow’s disease, or Marfan’s syndrome.

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⚠️ 2. Flail Mitral Leaflet – The Severe End

Definition:

Flail leaflet occurs when the tip of the mitral leaflet everts completely into the left atrium during systole due to rupture of chordae tendineae or papillary muscle.

Echocardiographic Features:

Leaflet tip moves beyond the annular plane, pointing toward the LA wall (“flapping” or “sail-like” motion).

Loss of coaptation between leaflets.

High-velocity, eccentric MR jet — usually anteriorly directed if posterior leaflet is flail.

Fluttering or erratic leaflet motion in 2D and M-mode.

Color Doppler: Dense, holosystolic MR with large flow convergence (PISA).

Causes:

Chordal rupture (degenerative, infective endocarditis, trauma, post-MI papillary dysfunction).

Severe myxomatous degeneration.

🧠 4. Imaging Tips

Always assess in multiple planes (PLAX, A3C, A4C).

Use color Doppler for MR jet direction — it helps localize the involved leaflet.

TEE (transesophageal echo) is the gold standard for precise localization and surgical planning.

3D echocardiography can visualize scallops and ruptured chordae beautifully.

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💬 5. Summary

> 👉 Prolapse = leaflet tip still coapts, bulges into LA

👉 Flail = leaflet tip flips into LA due to chordal rupture

Both are part of the degenerative mitral valve spectrum, but flail implies severe mechanical failure and significant MR, usually requiring surgical repair.

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🏥 Clinical Relevance

Recognizing flail vs prolapse on echo is not just an academic exercise — it directly affects:

MR grading (mild vs severe)

Timing of surgery

Feasibility of repair

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📚 Keywords & Hashtags

Keywords: Mitral valve, Flail leaflet, Mitral prolapse, Degenerative MR, Echocardiography, TEE, Myxomatous valve, FCPS Cardiology.

Hashtags:

#Echocardiography #MitralValve #FlailLeaflet #MitralProlapse #Cardiology #EchoCases #FCPSCardiology #MedicalEducation #PakistanCardiology #ValveDisease