Mitral regurgitation stages
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3]
Overview
The stage of mitral regurgitation (MR) can be estimated based on specific criteria for the valve anatomy, valve hemodynamics, associated cardiac findings, and symptoms. The stages of MR are the following: at risk of MR, progressive MR, asymptomatic severe MR, and symptomatic severe MR.
Primary Mitral Regurgitation Stages
Shown below is a table depicting the stages of mitral regurgitation adapted from the 2014 AHA/ACC guidelines for management of valvular heart disease.[1][2]
Abbreviations: ERO: Effective regurgitant orifice; IE: Infective endocarditis; LA: Left atrium; LV: Left ventricle; LVEF: Left ventricular ejection fraction; LVESD: Left ventricular end systolic dimension MR: Mitral regurgitation; MVP: Mitral valve prolapse
| Stage | Definition | Valve anatomy | Valve hemodynamics | Hemodynamic consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of MR | ❑ Mild MVP, normal coaptation ❑ Mild valve thickening and leaflet restriction |
❑ No MR jet area or central jet area < 20% LA on doppler ❑ Small vena contracta <0.3 cm |
Absent | Absent |
| B | Progressive MR | ❑ Severe MVP, normal coaptation ❑ Rheumatic valve changes with leaflet restriction and loss of central coaptation due to ❑ Previous infective endocarditis |
❑ Central jet area 20-40% LA or late systolic eccentric jet MR ❑ Vena contracta < 0.7 cm ❑ Regurgitant volume < 60 ml ❑ Regurgitant fraction <50 % ❑ ERO <0.40 cm2 ❑ Angiographic grade 1 - 2+ |
❑ Mild LA enlargement ❑ Absent LV enlargement ❑ Normal pulmonary pressure |
Absent |
| C | Asymptomatic severe MR | ❑ Severe MVP, flail leaflet ❑ Rheumatic valve changes with leaflet restriction, loss of central coaptation ❑ Prior IE ❑ Thickening of leaflets in case of radiation heart disease |
❑ Central jet 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 present at rest or with exercise ❑ C1: LVEF > 60% and LVESD < 40 mm ❑ C2: LVEF ≤ 60 % and LVESD ≥ 40 mm |
Absent |
| D | Symptomatic severe MR | ❑ Severe MVP, flail leaflet ❑ Rheumatic valve changes with leaflet restriction, loss of central coaptation ❑ Previous infective endocarditis ❑ Thickening of leaflets in case of radiation heart disease |
❑ Central jet 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 present |
❑ Decreased exercise tolerance ❑ Exertional dyspnea |
Secondary Mitral Regurgitation Stages
Shown below is a table depicting the stages of mitral regurgitation adapted from the 2020 AHA/ACC guidelines for management of valvular heart disease.[3]
*Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on data quality and integration of these parameters in conjunction with other clinical evidence.
†The measurement of the proximal isovelocity surface area by 2D TTE in patients with secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence.
‡May be lower in low-flow states.
2D indicates 2-dimensional; CAD, coronary artery disease; ERO, effective regurgitant orifice; HF, heart failure; LA, left atrium; LV, left ventricular; MR, mitral regurgitation; and TTE, transthoracic echocardiogram.
| Stage | Definition | Valve anatomy | Valve hemodynamics | Hemodynamic consequences | Symptoms |
|---|---|---|---|---|---|
| A | At risk of MR | ❑ Normal valve leaflets, chords, and annulus in a patient with CAD or cardiomyopathy | ❑ No MR jet area or central jet area < 20% LA on doppler ❑ Small vena contracta <0.3 cm |
❑ Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities ❑Primary myocardial disease with LV dilation and systolic dysfunction |
Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| B | Progressive MR | ❑ Regional wall motion abnormalities with mild tethering of mitral leaflet ❑Annular dilation with mild loss of central coaptation of the mitral leaflets |
❑ERO <0.40 cm2† ❑ Regurgitant volume <60 mL ❑Regurgitant fraction <50% |
❑Regional wall motion abnormalities with reduced LV systolic function ❑ LV dilation and systolic dysfunction attributable to primary myocardial disease |
Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| C | Asymptomatic severe 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 |
❑ ERO ≥0.40 cm2† ❑Regurgitant volume ≥60 mL‡ ❑ Regurgitant fraction ≥50% |
❑ Regional wall motion abnormalities with reduced LV systolic function ❑LV dilation and systolic dysfunction attributable to primary myocardial disease |
Symptoms attributable to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy |
| D | Symptomatic severe 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 |
❑ ERO ≥0.40 cm2† ❑ Regurgitant volume ≥60 mL‡ ❑ Regurgitant fraction ≥50% |
❑ Regional wall motion abnormalities with reduced LV systolic function ❑ LV dilation and systolic dysfunction attributable to primary myocardial disease |
❑HF symptoms attributable to MR persist even after revascularization and optimization of medical therapy ❑ Decreased exercise tolerance ❑ Exertional dyspnea |
References
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.
- ↑ Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. 129 (23): 2440–92. doi:10.1161/CIR.0000000000000029. PMID 24589852.
- ↑ Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F; et al. (2021). "2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 143 (5): e72–e227. doi:10.1161/CIR.0000000000000923. PMID 33332150 Check
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