Mitral Regurgitation

Use transthoracic echocardiography (TTE) to define leaflet motion, annular and subvalvular anatomy, LV size and systolic function, left atrial size, and pulmonary pressure estimates. Describe leaflet motion with the Carpentier classification because this links the observed jet to valve pathology and repair strategy. BMJBMJImaging assessment of mitral and aortic regurgitation: current state of the art | Heart

Classify MR as primary when the initiating lesion is within the valve apparatus, such as degenerative leaflet prolapse or flail and chordal abnormality. Classify MR as secondary when LV disease causes leaflet malcoaptation; this distinction is essential because natural history, severity interpretation, and treatment choices differ. BMJBMJImaging assessment of mitral and aortic regurgitation: current state of the art | Heart

Obtain transesophageal echocardiography (TEE) when TTE does not adequately define leaflet or chordal anatomy, when repairability is uncertain, or when transcatheter edge-to-edge repair (TEER) is being considered. Dedicated review of echocardiographic and cross-sectional imaging by experienced valve clinicians should precede a multidisciplinary decision on intervention. BMJ+1BMJImaging assessment of mitral and aortic regurgitation: current state of the art | HeartBMJGetting the best from the Heart Team: guidance for cardiac ...

For severe MR, integrate vena contracta, effective regurgitant orifice area (EROA), regurgitant volume, regurgitant fraction, jet characteristics, pulmonary venous flow, and ventricular response rather than making a decision from any isolated metric. The American Society of Echocardiography threshold cited for severe MR includes vena contracta greater than 0.7 cm, regurgitant volume greater than 60 mL, and regurgitant fraction greater than 50%. AHA JournalsAHA JournalsPercutaneous Interventions for Secondary Mitral Regurgitation

For holosystolic primary MR, EROA of at least 40 mm² and regurgitant volume of at least 60 mL are conventional severe-MR thresholds. Quantitative Doppler data likewise identified severe MR thresholds of 60 mL regurgitant volume, 50% regurgitant fraction, and 40 mm² effective orifice area. AHA Journals+1AHA JournalsGrading of Mitral Regurgitation by Quantitative Doppler ...ACCClinical Trial

Secondary MR requires special caution. An EROA of at least 20 mm² or regurgitant volume of at least 30 mL has been used as a severe-MR threshold in guideline-based frameworks, but PISA can substantially underestimate severity when the regurgitant orifice is elliptical or multiple jets are present. Consider three-dimensional EROA assessment when this limitation changes referral or procedural decisions, recognizing that three-dimensional imaging may overestimate actual EROA. ACCACCClinical Trial

For severe symptomatic MR, surgical mitral repair is the preferred therapeutic option when degenerative anatomy has a high likelihood of successful repair; valve replacement is the alternative when intervention is indicated but repair is not feasible or durable. jaccjaccThrombotic Risk and Antithrombotic Strategies After Transcatheter Mitral Valve Replacement

Refer patients being considered for mitral intervention through a multidisciplinary valve team that identifies lesion severity, the intended intervention, and the appropriate surgeon or operator. For degenerative disease amenable to repair, use a surgeon with dedicated mitral expertise and contemporary repair outcomes; referral to another center is appropriate when local repair expertise is insufficient. BMJBMJGetting the best from the Heart Team: guidance for cardiac ...

Use TEE-based segmental anatomy to distinguish lesions likely to support repair from those that may require replacement or transcatheter alternatives. The procedural plan should specify whether the valve is repairable before treatment selection, rather than treating all severe primary MR as interchangeable. BMJ+1BMJImaging assessment of mitral and aortic regurgitation: current state of the art | HeartBMJGetting the best from the Heart Team: guidance for cardiac ...

Secondary MR is common, increases with age, and is associated with excess mortality. Its treatment pathway should include a heart failure specialist because the valve lesion arises in the setting of LV disease and the expected benefit of intervention depends on patient phenotype. BMJ+1BMJGetting the best from the Heart Team: guidance for cardiac ...BMJBurden, treatment use, and outcome of secondary mitral ...

For patients with secondary MR being considered for intervention, perform Heart Team review after defining MR mechanism and severity, reviewing TTE and any CMR or other cross-sectional imaging, and determining the planned procedure. The multidisciplinary group should function as the entry point for patients under consideration for mitral intervention. BMJBMJGetting the best from the Heart Team: guidance for cardiac ...

TEER with MitraClip has randomized-trial evidence in selected patients with heart failure and secondary MR. COAPT was a multicenter randomized controlled trial of MitraClip in patients with heart failure and MR, and five-year follow-up reported lower rates of all hospitalizations and heart failure hospitalizations with transcatheter repair. NEJM+1NEJMFive-Year Follow-up after Transcatheter Repair ...NEJMTranscatheter Mitral-Valve Repair in Patients with Heart ... Divergent results between COAPT and MITRA-FR reinforce that secondary-MR phenotyping and patient selection are central rather than optional. BMJ+2BMJthe Gulf MTEER registry (GULF Mitral Transcatheter Edge ...Oxford AcademicThe management of secondary mitral regurgitation in patients ...Oxford AcademicRandomized controlled trials in valvular heart disease

Follow LV chamber size and function longitudinally after MR is identified, because contemporary guidance uses LV dimensions and ejection fraction as intervention triggers in asymptomatic patients. Interpret serial change with awareness that one linear measurement may miss nonuniform remodeling, particularly in primary MR. BMJBMJImaging assessment of mitral and aortic regurgitation: current state of the art | Heart

Use CMR or three-dimensional echocardiography selectively when TTE-derived quantification is limited by image quality, eccentric or multiple jets, or discordant ventricular remodeling. CMR offers more reproducible and accurate volumetric tracking than linear dimensions, although volumetric thresholds have not been established as guideline intervention triggers. BMJBMJImaging assessment of mitral and aortic regurgitation: current state of the art | Heart

Re-refer for multidisciplinary review when serial TTE shows worsening MR, evolving LV size or function, new uncertainty about repairability, or a change in candidacy for surgical or transcatheter intervention. Imaging should be available for expert review before the intervention decision is finalized. BMJ+1BMJImaging assessment of mitral and aortic regurgitation: current state of the art | HeartBMJGetting the best from the Heart Team: guidance for cardiac ...