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Overview

Practice Essentials

Mitral regurgitation (MR) is defined as an abnormal reversal of blood flow from the left ventricle (LV) to the left atrium (LA). It is caused by disruption in any part of the mitral valve (MV) apparatus. The most common etiologies of MR include MV prolapse (MVP), rheumatic heart disease, infective endocarditis, annular calcification, cardiomyopathy, and ischemic heart disease. See the video below.

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Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.

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Signs and symptoms

When associated with coronary artery disease (CAD) and acute myocardial infarction (MI), significant acute MR is accompanied by the following symptoms:

Dyspnea
Fatigue
Orthopnea
Pulmonary edema (often the initial manifestation)

The following may be noted with chronic MR:

Some patients may remain asymptomatic for years
Patients may have normal exercise tolerance until systolic LV dysfunction develops, at which point they may experience symptoms of a reduced forward cardiac output

Background

Mitral regurgitation (MR), the most frequent valvular heart disease,^{[4, 5, 6]}is defined as an abnormal reversal of blood flow from the left ventricle to the left atrium. It is caused by disruption in any part of the mitral valve apparatus, which comprises the mitral annulus, the leaflets (a large anterior [aortic] leaflet and a small posterior [mural] leaflet), the chordae tendineae, and the papillary muscles (anteromedial and posterolateral). The most common etiologies of MR include mitral valve prolapse (MVP), rheumatic heart disease, infective endocarditis, annular calcification, cardiomyopathy and ischemic heart disease. The pathophysiology, clinical manifestations and management of MR differ with the chronicity of the disease and the etiology.

For patient education resources, see Heart Health Center as well as Mitral Valve Prolapse.

Next: Background

Pathophysiology

Mitral regurgitation (MR) can be caused by organic disease (eg, rheumatic fever, ruptured chordae tendineae, myxomatous degeneration, leaflet perforation) or a functional abnormality (ie, a normal valve may regurgitate [leak] because of mitral annular dilatation, focal myocardial dysfunction, or both). Congenital MR is rare but is commonly associated with myxomatous mitral valve disease. Alternatively, it can be associated with cleft of the mitral valve, as occurs in persons with Down syndrome, or an ostium primum atrial septal defect.

Acute mitral regurgitation

Acute MR is characterized by an increase in preload and a decrease in afterload causing an increase in end-diastolic volume (EDV) and a decrease in end-systolic volume (ESV). This leads to an increase in total stroke volume (TSV) to supranormal levels. However, forward stroke volume (FSV) is diminished because much of the TSV regurgitates as the regurgitant stroke volume (RSV). This, in turn, results in an increase in left atrial pressure (LAP). According to the Laplace principle, which states that ventricular wall stress is proportional to both ventricular pressure and radius, LV wall stress in the acute phase is markedly decreased since both of these parameters are reduced.

Chronic compensated mitral regurgitation

In chronic compensated MR, the left atrium (LA) and ventricle have sufficient time to dilate and accommodate the regurgitant volume. Thus LA pressure is often normal or only minimally elevated. Because of the left ventricular dilatation via the process of eccentric hypertrophy, TSV and FSV are maintained. Wall stress may be normal to slightly increased as the radius of the LV cavity increases but the end-diastolic LV pressure remains normal. As the LV progressively enlarges, the mitral annulus may stretch and prevent the mitral valve leaflets from coapting properly during systole, thus worsening the MR and LV dilatation.

Chronic decompensated mitral regurgitation

In the chronic decompensated phase, cardiac dysfunction has developed, impairing both TSV and FSV (although ejection fraction still may be normal). This results in a higher ESV and EDV, which in turn causes a elevation of LV and LA pressure, ultimately leading to pulmonary edema and, if left untreated, cardiogenic shock.

Next: Background

Etiology

Acute mitral regurgitation

Causes of acute mitral regurgitation (MR) include coronary artery disease, infectious endocarditis, chordae tendineae rupture (as with myxomatous valve disease), valvular surgery, and other conditions.

Coronary artery disease (ischemia or acute myocardial infarction) may result in papillary muscle dysfunction or rupture; it does not cause chordae tendineae dysfunction or rupture as they are not vascularized. The posteromedial papillary muscle is supplied by the terminal branch of the posterior descending artery and is more vulnerable to ischemic insult than the anterolateral papillary muscle, which is usually supplied by both the left anterior descending and circumflex arteries. Transient ischemia may result in transient MR associated with angina. Myocardial infarction or severe prolonged ischemia produces irreversible papillary muscle dysfunction and scarring.

Infectious endocarditis features include the following:

Abscess formation
Vegetations
Rupture of chordae tendineae
Leaflet perforation

Following valvular surgery, acute MR may occur as a result of trauma, percutaneous valvuloplasty, or suture interruption.

Other causes of acute MR include the following:

Tumors (most commonly atrial myxoma)
Myxomatous degeneration (mitral valve prolapse, Ehlers-Danlos syndrome, Marfan syndrome)
Ruptured chordae tendineae (trauma, mitral valve prolapse, endocarditis, spontaneous)
Systemic lupus erythematosus (Libman-Sacks lesion)
Acute rheumatic fever (Carey Coombs murmur)
Acute global left ventricular dysfunction
Prosthetic mitral valve dysfunction

Chronic mitral regurgitation

Causes of chronic MR include the following:

Rheumatic heart disease
Systemic lupus erythematosus
Scleroderma
Myxomatous degeneration (mitral valve prolapse, Ehlers-Danlos syndrome, Marfan syndrome)
Calcification of mitral valve annulus
Infective endocarditis (can affect normal, abnormal, or prosthetic mitral valves)
Ruptured chordae tendineae (trauma, mitral valve prolapse, endocarditis, spontaneous)
Functional MR (dilation of mitral valve annulus, anormal tethering of leaflets due to enlargement of LV cavity and stretch of papillary muscles and chordae [dilated cardiomyopathies, aneurysmal dilation of the left ventricle])
Hypertrophic cardiomyopathy
Systolic anterior motion of the mitral valve
Perivalvular prosthetic leak
Congenital (mitral valve clefts, mitral valve fenestrations, parachute mitral valve abnormality)
Drug-related (ergotamine, methysergide, pergolide, anorexiant medications)

Next: Background

Epidemiology

United States data

Acute and chronic mitral regurgitation (MR) affect approximately 5 in 10,000 people. Mitral valve disease is the second most common valvular lesion, preceded only by aortic stenosis. Myxomatous degeneration has replaced rheumatic heart disease as the leading cause of mitral valvular abnormalities. Mitral valve prolapse has been estimated to be present in 4% of the normal population. With the aid of color Doppler echocardiography, mild MR can be detected in as many as 20% of middle-aged and older adults. MR is independently associated with female sex, lower body mass index, advanced age, renal dysfunction, prior myocardial infarction, prior mitral stenosis, and prior mitral valve prolapse. It is not related to dyslipidemia or diabetes.

International data

In areas other than the Western world, rheumatic heart disease is the leading cause of MR.

Next: Background

Prognosis

There appears to be an association between recurrent mitral regurgitation (MR) after mitral valve (MV) repair in patients with degenerative MR and increased mortality and adverse LV remodeling.^[7]Independent risk factors for recurrent MR after mitral valve repair include MV repair performed before 2000, preoperative atrial fibrillation, high LV end-diastolic dimension (LVEDD), prolapse of the isolated anterior leaflet or multiple segments, and absence of ring annuloplasty. LVEDD and repair without artificial chordae implantation appear to be predictors of MR progression.^[7]

Outcomes for asymptomatic chronic severe degenerative MR are as follows:

Mortality ranges from 50-73% at 5 years.
Mortality in patients with preserved LV function ranges from 27-45%.
Sudden death may be as common as 1-8% per year in patients with a flail leaflet.

In a study of patients with low ejection fraction (EF) (regardless of ischemic or nonischemic etiology), the presence of functional MR is associated with a 2-fold greater risk of all-cause mortality and hospitalization at 1-5 years.^[8]

Mitral valve surgery operative mortality includes the following:

Isolated mitral valve repair surgery carries a 2% mortality.
Mitral valve replacement surgery: 4% mortality for patients younger than 50 years; 17% mortality for patients older than 80 years.

Tribouilloy et al found that, in patients with organic MR due to flail leaflets, left ventricular end-systolic diameter (LVESD) is independently associated with increased mortality. Analysis of results in 739 patients showed that LVESD ≥ 40 mm independently predicted overall mortality (hazard ratio [HR] 1.95; 95% confidence interval [CI], 1.01-3.83) and cardiac mortality (HR 3.09; 95% CI, 1.35-7.09) under conservative management. Mortality risk increased linearly with LVESD >40 mm (HR 1.15; 95% CI, 1.04-1.27 per 1-mm increment). Tribouilloy et al conclude that these findings support prompt surgical rescue in patients with LVESD ≥40 mm but also suggest that operating on patients before LVESD reaches 40 mm will best preserve survival.^[9]

Magne et al found that exercise pulmonary hypertension can be predicted using resting comprehensive echocardiography in asymptomatic patients with degenerative MR.^[10]

Clinical Presentation

[Guideline] Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J. 2012 Oct. 33(19):2451-96. [QxMD MEDLINE Link]. [Full Text].
O'Riordan M. FDA approves MitraClip for degenerative MR. Heartwire from Medscape. October 25, 2013. Available at https://www.medscape.com/viewarticle/813216. Accessed: October 28, 2013.
Abbott. Abbott's first-in-class MitraClip device now available for U.S. patients [press release]. October 25, 2013. Available at https://www.abbott.com/press-release/abbotts-firstinclass-mitraclip-device-now-available-for-us-patients.htm. Accessed: October 28, 2013.
Sharma A, Goel S, Agrawal S. Percutaneous mitral valve interventions and heart failure. Adv Exp Med Biol. 2018. 1067:271-85. [QxMD MEDLINE Link].
Crousillat DR, Wood MJ. Valvular heart disease and heart failure in women. Heart Fail Clin. 2019 Jan. 15(1):77-85. [QxMD MEDLINE Link].
Eleid MF, Thaden JJ. Mitral annulus enlargement in mitral regurgitation: look to the north. Int J Cardiol. 2019 Jan 1. 274:261-2. [QxMD MEDLINE Link]. [Full Text].
Kim JH, Lee SH, Joo HC, et al. Effect of recurrent mitral regurgitation after mitral valve repair in patients with degenerative mitral regurgitation. Circ J. 2017 Dec 25. 82(1):93-101. [QxMD MEDLINE Link].
Rossi A, Dini FL, Faggiano P, et al. Independent prognostic value of functional mitral regurgitation in patients with heart failure. A quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart. 2011 Oct. 97(20):1675-80. [QxMD MEDLINE Link].
Tribouilloy C, Grigioni F, Avierinos JF, et al. Survival implication of left ventricular end-systolic diameter in mitral regurgitation due to flail leaflets a long-term follow-up multicenter study. J Am Coll Cardiol. 2009 Nov 17. 54(21):1961-8. [QxMD MEDLINE Link].
Magne J, Lancellotti P, O'Connor K, et al. Prediction of exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. J Am Soc Echocardiogr. 2011 Sep. 24(9):1004-12. [QxMD MEDLINE Link].
Bach DS. 2017 ACC expert consensus decision pathway for mitral regurgitation. American College of Cardiology. October 18, 2017. Available at https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/10/18/09/33/2017-acc-expert-consensus-decision-on-mr. Accessed: June 27, 2018.
[Guideline] O'Gara PT, Grayburn PA, Badhwar V, et al. 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Task Force on Expert Consensus Decision Pathways. J Am Coll Cardiol. 2017 Nov 7. 70(19):2421-49. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Nishimura RA, Otto CM, Bonow RO, et al, for the ACC/AHA Task Force Members. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014 Jun 10. 129(23):e521-643. [QxMD MEDLINE Link]. [Full Text].
Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol. 2009 Sep 15. 54(12):1099-106. [QxMD MEDLINE Link].
Jung JC, Jang MJ, Hwang HY. Meta-analysis comparing mitral valve repair versus replacement for degenerative mitral regurgitation across all ages. Am J Cardiol. 2019 Feb 1. 123(3):446-53. [QxMD MEDLINE Link].
Hata M, Zittermann A, Hakim-Meibodi K, Borgermann J, Gummert J. Minimally invasive mitral valve repair or replacement for degenerative mitral regurgitation. Interact Cardiovasc Thorac Surg. 2019 Apr 1. 28(4):575-80. [QxMD MEDLINE Link].
Otto CM, Bonow RO. Valvular heart disease. In: Libby PP, Bonow RO, MD, Mann DL, Zipes DP, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philadelphia, PA: Saunders Elsevier; 2007. 1625-712.
Thourani VH, Weintraub WS, Guyton RA, et al. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting. Circulation. 2003 Jul 22. 108(3):298-304. [QxMD MEDLINE Link].
Vahanian A, Iung B. Mitral regurgitation. Timing of surgery or interventional treatment. Herz. 2016 Feb. 41(1):3-9. [QxMD MEDLINE Link].
Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation. 2006 May 9. 113(18):2238-44. [QxMD MEDLINE Link].
O’Riordan M. Early surgery bests "watchful waiting" in severe MR patients without symptoms. Medscape Medical News. August 19, 2013. Available at https://www.medscape.com/viewarticle/809403. Accessed: August 25, 2013.
Suri RM, Vanoverschelde JL, Grigioni F, et al. Association between early surgical intervention vs watchful waiting and outcomes for mitral regurgitation due to flail mitral valve leaflets. JAMA. 2013 Aug 14. 310(6):609-16. [QxMD MEDLINE Link].
Otto CM. Surgery for mitral regurgitation: sooner or later?. JAMA. 2013 Aug 14. 310(6):587-8. [QxMD MEDLINE Link].
[Guideline] Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. 2007 Oct 9. 116(15):1736-54. [QxMD MEDLINE Link]. [Full Text].
O'Riordan M. Repair and surgery fare equally well in ischemic MR. Heartwire from Medscape. November 18, 2013. Available at https://www.medscape.com/viewarticle/814529. Accessed: November 21, 2013.
Barbieri A, Bursi F, Grigioni F, et al. Prognostic and therapeutic implications of pulmonary hypertension complicating degenerative mitral regurgitation due to flail leaflet: a multicenter long-term international study. Eur Heart J. 2011 Mar. 32(6):751-9. [QxMD MEDLINE Link].
Matsunaga A, Duran CM. Progression of tricuspid regurgitation after repaired functional ischemic mitral regurgitation. Circulation. 2005 Aug 30. 112(9 suppl):I453-7. [QxMD MEDLINE Link].
[Guideline] Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2. 143(5):e35-e71. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the management of patients with valvular heart disease: a report of the of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Feb 2. 143(5):e72-e227. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Vahanian A, Beyersdorf F, Praz F, et al, for the ESC/EACTS Scientific Document Group; ESC Scientific Document Group. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021 Aug 28. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2017 Jul 11. 70 (2):252-89. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Falk V, Baumgartner H, Bax JJ, et al, for the ESC Scientific Document Group. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017 Oct 1. 52(4):616-64. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Kron IL, LaPar DJ, Acker MA, et al, for the AATS Ischemic Mitral Regurgitation Consensus Guidelines Writing Committee. 2016 update to The American Association for Thoracic Surgery (AATS) consensus guidelines: ischemic mitral valve regurgitation. J Thorac Cardiovasc Surg. 2017 May. 153(5):e97-e114. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21. 36(44):3075-128. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Baddour LM, Wilson WR, Bayer AS, et al. Infective endocarditis in adults: diagnosis, antimicrobial therapy, and management of complications: a scientific statement for healthcare professionals from the American Heart Association. Circulation. 2015 Oct 13. 132(15):1435-86. [QxMD MEDLINE Link]. [Full Text].
Kim MJ, Jung HO. Pulmonary hypertension: a long-term risk stratifier in primary mitral regurgitation. Ann Transl Med. 2016 Dec. 4(24):541. [QxMD MEDLINE Link]. [Full Text].
Scarfo I, La Canna G. Is pulmonary artery pressure a trigger of adverse outcome in mitral regurgitation?. Ann Transl Med. 2016 Dec. 4(24):498. [QxMD MEDLINE Link]. [Full Text].
Kaneko H, Neuss M, Weissenborn J, Butter C. Prognostic significance of right ventricular dysfunction in patients with functional mitral regurgitation undergoing MitraClip. Am J Cardiol. 2016 Dec 1. 118(11):1717-22. [QxMD MEDLINE Link].
Fino C, Iacovoni A, Ferrero P, et al. Determinants of functional capacity after mitral valve annuloplasty or replacement for ischemic mitral regurgitation. J Thorac Cardiovasc Surg. 2015 Jun. 149(6):1595-603. [QxMD MEDLINE Link].
Feldman T, Cilingiroglu M. Percutaneous leaflet repair and annuloplasty for mitral regurgitation. J Am Coll Cardiol. 2011 Feb 1. 57(5):529-37. [QxMD MEDLINE Link].
Feldman T, Foster E, Glower DG, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med. 2011 Apr 14. 364(15):1395-406. [QxMD MEDLINE Link].
Castleberry AW, Williams JB, Daneshmand MA, et al. Surgical revascularization is associated with maximal survival in patients with ischemic mitral regurgitation: a 20-year experience. Circulation. 2014 Jun 17. 129(24):2547-56. [QxMD MEDLINE Link]. [Full Text].
Zhaohua Y, Wei F, Fei X, Jiqiang Z, Junzhe D, Yangwu S. Concomitant CABG, left ventricular restoration and mitral valve repair for ischemic heart disease. Heart Surg Forum. 2016 Dec 6. 19(6):E272-E275. [QxMD MEDLINE Link].
Feldman T, Kar S, Elmariah S, et al, for the EVEREST II Investigators. Randomized comparison of percutaneous repair and surgery for mitral regurgitation: 5-Year results of EVEREST II. J Am Coll Cardiol. 2015 Dec 29. 66(25):2844-54. [QxMD MEDLINE Link].
Hachinohe D, Latib A, Agricola E, Colombo A. Repeat MitraClip for early recurrent mitral regurgitation. Catheter Cardiovasc Interv. 2018 Sep 1. 92(3):611-6. [QxMD MEDLINE Link].
Acker MA, Parides MK, Perrault LP, et al for The Cardiothoracic Surgical Trials Network. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2014 Jan 2. 370(1):23-32. [QxMD MEDLINE Link]. [Full Text].
Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol. 2005 Apr 19. 45(8):1334-40. [QxMD MEDLINE Link].
Carabello BA. Progress in mitral and aortic regurgitation. Prog Cardiovasc Dis. 2001 May-Jun. 43(6):457-75. [QxMD MEDLINE Link].
Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005 Mar 3. 352(9):875-83. [QxMD MEDLINE Link].
Fann JI, Ingels NB, Miller DC. Pathophysiology of mitral valve disease. In: Cohn LH, Edmunds LH (eds). Cardiac Surgery in the Adult. 4th ed. New York: McGraw-Hill; 2012. 795-827.
Khanna D, Miller AP, Nanda NC, et al. Transthoracic and transesophageal echocardiographic assessment of mitral regurgitation severity: usefulness of qualitative and semiquantitative techniques. Echocardiography. 2005 Oct. 22(9):748-69. [QxMD MEDLINE Link].
Mehta RH, Eagle KA, Coombs LP, et al. Influence of age on outcomes in patients undergoing mitral valve replacement. Ann Thorac Surg. 2002 Nov. 74(5):1459-67. [QxMD MEDLINE Link].

Media Gallery

Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.

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Table 1. Stages of Progression of Chronic Mitral Regurgitation

Table 1. Stages of Progression of Chronic Mitral Regurgitation

Stage	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A: Primary MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	None	None
A: Secondary MR	Normal valve leaflets, chords and annulus in patient with CAD or cardiomyopathy	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	Normal or mildly dilated LV with infarction or ischemia regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
B: Primary MR	Severe MV prolapse with normal coaptation Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE	Central jet MR area 20-40% LA or late systolic eccentric jet MR Vena contracts < 0.7 cm Regurgitant volume < 60 mL Regurgitant fraction < 50% ERO < 0.40 cm² Angiographic grade 1-2+	Mild LA enlargement No LV enlargement Normal Pulmonary pressure	None
B: Secondary MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	Regurgitant volume < 30 mL Regurgitant fraction < 50% ERO < 0.20 cm^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
C: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm² Angiographic grade 3-4+	Moderate to severe LA enlargement LV enlargement Pulmonary hypertension may be present Stage C1: LVEF >60% and LVESD < 40 mm Stage C2: LVEF ≤60% and LVESD ≥40 mm	None
C: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
D: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm² Angiographic grade 3-4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present	Decreased exercise tolerance Exertional dyspnea
D: Secondary MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	HF symptoms due to MR persist after revascularization and medical therapy Decreased exercise tolerance Exertional dyspnea
*Several criteria are provided but not all criteria for each category will be present. Severity of mild, moderate, or serve is dependent on data quality and integration with other clinical evidence. ^†In secondary MR, true ERO is underestimated due to the crescentic shape of the proximal convergence
CAD = coronary heart disease; ERO = effective regurgitation orifice; HF = heart failure; IE = infective endocarditis; LA = left atrium; LV = left ventricular; LVEF = left ventricular ejection factor; LVESD = left ventricular end-systolic dimension; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiography.

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#author-disclosures{display:block}#author-disclosures.modal-layer{position:relative}#author-disclosures .modal-content{max-height:none}#author-disclosures .close-modal{display:none}

Author

Ivan Hanson, MD Assistant Professor of Medicine, Oakland University William Beaumont School of Medicine

Ivan Hanson, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Luis C Afonso, MD Assistant Professor, Department of Internal Medicine-Cardiology, Program Director of Cardiology Fellowship Program, Wayne State University; Director of Echocardiography Laboratory, Harper University Hospital

Luis C Afonso, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, American Society of Echocardiography

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, American Thoracic Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, United Therapeutics<br/>Received research grant from: Actelion, Arena, Gilead, GSK, Liquidia, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Complexa, Gilead, Medtronic, Reata, United Therapeutics.

Chief Editor

Terrence X O'Brien, MD, MS, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina College of Medicine; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, MS, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Shivkumar H Jha, MD; Jatin Dave, MD, MPH; Kishorkumar Desai, MD; and Abraham G Kocheril, MD, FACC, FACP to the development and writing of this article.