Priya Panday, MD

Superior displacement of the mitral valve into the LA increases traction exerted on the papillary muscles. As a result, the myocardium beneath the papillary muscles is pulled into the LV cavity. This causes the LV crest as well as the posterior annuus and the attached posterior leaflet to rotate (as a unit) in the counterclockwise direction. This motion is called curling. Papillary muscle traction also pulls the basal posterior wall in the apical direction. This brisk motion causes a prominent s’ wave on tissue Doppler imaging. An s’ > 16 cm/s is called the Picklehaube sign. #ASEchoJC

#ASEchoJC Q 10 What are curling and the Picklehaube sign and how are these related to papillary muscle traction? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve #ASEchoJC #EchoFirst #CardioTwitter #EPeeps #MVP @ASE360 @JournalASEcho

When MAD and MR are present in patients with MVP, some of the blood that might otherwise be ejected into the aorta and regurgitated into the LA instead expands the (potential) space between the LV crest and PML-LA junction (MAD volume) as well as the potential space contained within the mitral valve (prolapse volume. Since these volumes are retained in the LV they contribute to LV volume overload apart from the contribution of MR volume. The increase in LV end-diastolic volume resulting from MAD and prolapse volumes might account for what some authors attribute to MVP-related cardiomyopathy. #ASEchoJC

#ASEchoJC Q 8 How do MAD and prolapse volume contribute to LV overload and MVP-related cardiomyopathy? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve #ASEchoJC #EchoFirst #CardioX #MVP @ASE360 @JournalASEcho

Arrhythmic MVP is associated with ventricular arrhythmias and in some cases sudden arrhythmic death. Echo findings which are associated increased arrhythmic risk include: bi-leaflet prolapse, thick long leaflets, MAD length > 8.5 mm, Picklehaube sign, curling, severe MR. Strain findings include: the double peak sign and mechanical dispersion. #ASEchoJC

#ASEchoJC Q 7 What defines arrhythmic MVP, and which findings are associated with higher ventricular arrhythmia risk? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho #EPeeps #ASEchoJC #EchoFirst #CardioX #MVP

The normal mitral annulus is a compact collagenous, more or less circular structure that connects the LV and LA. In contrast, the disjunctive annulus is elongated and its length is dynamic. During systole the annulus reaches its maximal length. During diastole it recoils and decreases in length. In patients with a markedly redundant posterior leaflet, the leaflet’s base gets pressed against the LA, simulating systolic MAD. This is called pseudo-MAD. Unlike true MAD, there is no elongated separation between the LA and LV in pseudo-MAD. The increased leaflet length associated with pseudo-MAD increases MR severity. MAD is believed to be an echo marker in increased arrhythmic risk especially when it is located along the P2 scallop. In addition, the circumferential extent of MAD may increase MR. #ASEchoJC

#ASEchoJC Q 6 What is mitral annular disjunction (MAD), how is it distinguished from pseudo-MAD, and why is it important? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho

In general, jets due to MVP course away from the prolapsing leaflet. Jets which arise near the LV wall, i.e., those due to commissural prolapse, sometimes course along the atrial surface of the mitral valve (“sideways MR”). When viewed in the 3 chamber view these jets can be underestimated because they are seen en face. Moreover, commissural jets arise close to the LV wall. As a result, their convergence zone is truncated. When EROA is calculated a correction factor must be used: ß/180°, where ß is the angle formed by the LV wall and the base of the convergence zone. Another pitfall in measuring EROA is failure to recognize that MR is late systolic. Since there is no MR is early systole, any MR measurement that is instantaneous, e.g., jet area, EROA, vena contracta, will overestimate MR severity. #ASEchoJC'

#ASEchoJC Q 5 What are the characteristic MR jet patterns in MVP, and what are the pitfalls in MR quantification? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve

@HeartToProve @SIwa23288585 @PWesslyMD Always appreciate food-related concepts!

@SIwa23288585 @PWesslyMD #ASEchoJC I prefer a "Pringles" shaped annulus

@PWesslyMD Very educational—an important reminder that MVP should be defined in the PLAX view, given the saddle-shaped mitral annulus. Thank you for sharing🥹

The major syndromic forms of MVP are associated with inherited connective tissue disorders, particularly Marfan syndrome, Loeys-Dietz syndrome, and Ehlers-Danlos syndrome. These disorders affect connective tissue integrity and predispose patients to myxomatous degeneration of the mitral valve, resulting in leaflet prolapse and mitral regurgitation. Because MVP occurs as part of a systemic disorder, affected individuals may also have aortic, skeletal, skin, and joint abnormalities that require ongoing surveillance and management. #ASEchoJC

#ASEchoJC Q 3 What are the major syndromic forms of MVP and their associated genetic and cardiovascular features? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho

However, fibroelastic deficiency is a localized degenerative process, usually involving the P2 scallop (Figure C), with thin leaflets and chordae and relatively normal surrounding valve tissue. Generally it presents in older patients and often becomes clinically evident after chordal rupture causes acute or subacute severe holosystolic mitral regurgitation. #ASEchoJC

@PWesslyMD @LucySafi @NadeenFaza @HeartToProve @ASE360 @purviparwani @iamritu @DavidWienerMD @JournalASEcho @SIwa23288585 @boegel_kelly @EACVIPresident Barlow’s disease is characterized by diffuse myxomatous degeneration with thickened, redundant leaflets, elongated chordae, and multisegment or bileaflet prolapse (Figure A, B). It typically incidentally found in younger patients and progresses slowly over many years.

#ASEchoJC Q 2 How do Barlow's disease and fibroelastic deficiency differ in morphology, genetics, and clinical presentation? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360

Great question! Mitral valve prolapse (MVP) is defined as >2 mm systolic displacement of one or both mitral valve leaflets beyond the annular plane into the left atrium, best seen in the parasternal long-axis view. MVP affects approximately 2–3% of the population and is not always benign. It is associated with heart failure, infective endocarditis, ventricular arrhythmias, myocardial fibrosis, and sudden cardiac death in a subset with “arrhythmogenic MVP,” wherein bileaflet prolapse, mitral annular disjunction (MAD), fibrosis, and ventricular ectopy coexist. #ASEchoJC

#ASEchoJC Q 1 What are the echocardiographic definition, prevalence, and clinical importance of mitral valve prolapse (MVP)? @LucySafi @PriyaPanday27 @NadeenFaza @HeartToProve @ASE360 @JournalASEcho #Echofirst #MVP #CardioX

Join us this Tuesday from 8-9 PM ET for our ASE Journal Club on X! #ASEchoJC The live social event will be moderated by @NadeenFaza, @PWesslyMD & @HeartToProve. Guest authors include @LucySafi, Priya Panday, MD & Jeffrey J. Silbiger, MD, FASE. Both will post from @PriyaPanday27.

Huge congratulations to our newest class of fellows joining us in July 2026! Welcome to the team!

We couldn’t focus during noon conference today because we were too excited to find out who will be joining our family next year! Welcome welcome and congratulations!! 😍 #CardioTwitter #Match2022 @MountSinaiHeart

Black and brown people around the world who were subject to horrendous cruelties and economic deprivation under British colonialism are allowed to have feelings about Queen Elizabeth. After all, they were her "subjects" too.

Just a friendly reminder that what has become routine to you, may be one of the scariest times in your patient’s life.

My latest @TEDTalks was posted on YouTube. Free for everyone, and I hope it helps. I offer 3 ways in which you can invest in hope in what seems like hopeless times. youtu.be/bIw5ZLITSfo

Wearing a mask protects others from you much more than it protects you yourself. But if everyone wears a mask, then everyone is protected. The only reason why some people refuse to wear a mask is because of a selfish lack of concern for others. Enough. We’re all in this together.

3/ major hospital based specialists will be significantly cut in’21 by Medicare in the midst of a global pandemic—@emergencydocs -6%, anesthesiologists-8%, radiology -11% and IR -9%. Congress & @CMSGov here they come—Table 90, page 899.

The unfortunate reality of the disparities between Bellevue and NYU Langone, just blocks away from each other. The Mistakes New York Made The Daily open.spotify.com/episode/5DP0t1…

Hello #medtwitter friends, I just got into a huge fight with my parents because they told me that my future career is at risk from all my anti-police brutality protesting. So I want to be very clear: no career is worth the lives of any more Black people.