Mitral regurgitation

Last updated: July 12, 2022

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Mitral regurgitation (MR) is the leakage of blood from the left ventricle into the left atrium due to incomplete closure of the mitral valve during systole. It is a common form of valvular disease and categorized according to onset (into acute and chronic forms) and etiology. Primary MR involves the structure of the mitral valve whereas secondary MR is a result of different pathologies that lead to valvular incompetence (e.g., cardiomyopathy). Ischemic MR can be acute (e.g., papillary muscle rupture in myocardial infarction) or chronic (in coronary artery disease). Symptoms vary from cardiogenic shock and flash pulmonary edema in acute manifestations to mild symptoms such as cough and dyspnea in chronic cases. Echocardiography is the diagnostic modality of choice; further imaging and treatment options are determined by the etiology. The definitive treatment in primary MR is surgical repair or valve replacement, while therapy of an underlying condition, e.g., percutaneous coronary intervention (PCI) in coronary artery disease, is the mainstay of therapy in secondary MR. Pharmacological treatment aims to reduce the degree of heart failure.


Acute mitral regurgitation [5]

Chronic mitral regurgitation

American Heart Association (AHA) staging for MR [9][10]

  • Used to monitor intervals and determine the need for interventions
  • Based on echocardiographic criteria of valve anatomy, hemodynamics, and associated cardiac findings (e.g., LV dilation)
  • Criteria vary between primary and secondary MR.
AHA staging for mitral valve regurgitation [9][10]
Stage Extent of mitral regurgitation
  • At risk of MR (minimal regurgitation)
  • Progressive MR (moderate regurgitation)
  • Asymptomatic severe MR (LVEF > 60%)
  • Asymptomatic severe MR (LVEF ≤ 60%)
  • Severe symptomatic MR

Carpentier classification

  • Uses echocardiography findings to classify leaflet motion (Carpentier types I–III). [1][11]
  • Used in the planning of surgical repair

Transthoracic echocardiography (TTE) is used to confirm the diagnosis and classify severity in patients with suspected MR. Check ECG and troponin in acute MR to rule out myocardial infarct. Consider additional diagnostics (e.g., coronary angiography, blood cultures) depending on patient stability and the suspected underlying condition.


  • Indications: to assess the valve apparatus, size and function of left ventricle and atrium, and grade the severity of MR [6]
    • TTE: modality of choice for the initial assessment of all patients with suspected valvular abnormality [5][6]
    • Transesophageal echocardiography (TEE): indicated prior to surgery and during the diagnostic workup of MR if TTE is inadequate [1][6]

Findings [5][9][10]

Echocardiographic characteristics of primary mitral regurgitation
Parameter Acute MR Chronic MR
Valve movement or function
  • Abnormal
  • Abnormal
Aortic valve opening [12]
  • Decreased
  • Decreased
Pulmonary vein flow [13]
  • May be reversed
  • Generally normal
Left atrium
  • Normal
  • Dilated
Left ventricle size
  • Normal
  • Increased/remodeled
  • Normal
  • Compensated: normal or increased [14]
  • Decompensated: decreased [15]
Pulmonary artery pressure [16][17]
  • Elevated
  • Compensated: normal
  • Decompensated: elevated
Right ventricle ejection fraction
  • Normal
  • Compensated: normal
  • Decompensated: reduced [16][18]

Laboratory studies

Myocardial infarction must be ruled out in patients presenting with acute mitral regurgitation!


Chest x-ray

Additional evaluation

In primary MR, additional diagnostics should be considered if echocardiography does not allow for the adequate assessment of mitral valve function. In secondary MR, consider advanced diagnostics to determine the underlying condition (e.g., coronary artery disease).

Acute mitral regurgitation

General principles

Surgical therapy [5]

All patients with acute primary MR should undergo urgent surgical repair or valve replacement.

Medical therapy

For acute primary MR, medical treatment is usually only a temporizing measure while surgery is planned. The aim is to reduce the symptoms of heart failure and improve forward flow.

Heart failure treatment may worsen hypotension; use caution in hemodynamically unstable patients.

Bridging devices

Chronic mitral regurgitation

Management of chronic MR is guided by the symptoms and extent of heart failure and the cause of MR. Medical therapy should be initiated in all patients to optimize cardiac function but surgery is the definitive treatment option.

Medical management

Surgical management and transcatheter mitral repair

  • Chronic primary MR
    • Indications [1][9]
      • Asymptomatic patients with LV dysfunction (LVEF 30–60%; or LV end-systolic diameter ≥ 40 mm) (stage C2)
      • Symptomatic patients with LVEF 30–60 % (stage D)
    • Contraindications: Once LVEF is < 30%, surgery is generally not recommended because of the high mortality rate and low likelihood of symptom improvement. [11]
    • Procedure
      • Valve repair is preferred to replacement because it is associated with reduced mortality and fewer complications. [25]
      • Transcatheter mitral valve procedures, such as a clip device, can be considered in patients who are considered to be unsuitable for surgical repair and severely symptomatic. [1]
  • Chronic secondary MR [9] [6]
    • Indications: consider for patients with severe MR and persistent symptomatic heart failure (NYHA classes III–IV) despite optimal medical management [9]
    • Procedure:

We list the most important complications. The selection is not exhaustive.

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