Home

Loading...

Table of contents

Mitral regurgitation

Background

Overview

Definition
MR is a form of structural heart disease characterized by abnormal systolic flow of blood across the mitral valve, from the left ventricle to the left atrium.
1
Pathophysiology
Mechanisms of MR can broadly be classified into primary causes and secondary causes. Patients with primary MR are grouped according to the Carpentier classification (type 1 MR: normal leaflet size and motion; type 2 MR: excessive leaflet motion; type 3a MR: leaflet restriction in diastole; type 3b: leaflet restriction in systole).
2
Epidemiology
The prevalence of MR in the US is estimated at 1,700 patients per 100,000 population.
1
Prognosis and risk of recurrence
Significant MR is associated with an adjusted hazard ratio for mortality of 1.83 (95% CI 1.28 to 2.62, p < 0.001) as compared with matched controls.
3

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of mitral regurgitation are prepared by our editorial team based on guidelines from the Society of Thoracic Surgeons (STS 2024), the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ACC 2021), the European Society of Cardiology (ESC 2021), and the European Society of Cardiology (ESC/EACTS 2021). ...
Show more

Diagnostic investigations

TTE: as per ACC/AHA 2021 guidelines, obtain a TTE for baseline evaluation of LV size and function, RV function, LA size, pulmonary artery pressure, and the mechanism and severity of primary MR (stages A to D) in patients with known or suspected primary MR.
B
Show 3 more
Create free account

More topics in this section

  • TEE

  • Exercise stress testing

  • Cardiac MRI

  • Cardiac biomarkers

Diagnostic procedures

Cardiac catheterization: as per ACC/AHA 2021 guidelines, consider performing cardiac catheterization in patients with primary MR (stages B and C) and symptoms likely attributable to MR.
C

Medical management

Management of systolic dysfunction
As per ACC/AHA 2021 guidelines:
Consider initiating guideline-directed medical therapy for systolic dysfunction in symptomatic or asymptomatic patients with severe primary MR and LV systolic dysfunction (stages C2 and D) if surgery is not possible or must be delayed.
C
Initiate standard guideline-directed medical therapy for HF, including ACEIs, ARBs, β-blockers, aldosterone antagonists, and/or sacubitril/valsartan, and biventricular pacing, in patients with chronic severe secondary MR (stages C and D) and HF with reduced LVEF.
A

More topics in this section

  • Antihypertensive therapy

  • Vasodilator therapy

Perioperative care

Intraoperative imaging
As per ACC/AHA 2021 guidelines:
Obtain intraoperative TEE to establish the anatomic basis for primary MR (Stages C and D) and to guide repair in patients with severe primary MR undergoing mitral intervention.
B
Obtain intraprocedural TEE for guidance in patients with chronic secondary MR undergoing transcatheter mitral valve intervention.
B

Surgical interventions

Mitral valve repair, primary MR, symptomatic patients: as per ACC/AHA 2021 guidelines, perform mitral valve intervention in symptomatic patients with severe primary MR (stage D), irrespective of LV systolic function.
B
Show 4 more

More topics in this section

  • Mitral valve repair, primary MR (asymptomatic patients)

  • Mitral valve repair, secondary MR

Specific circumstances

Patients with coronary artery disease
As per ACC/AHA 2021 guidelines:
Consider performing chordal-sparing mitral valve replacement instead of downsized annuloplasty repair in patients with coronary artery disease and chronic severe secondary MR related to LV systolic dysfunction (LVEF < 50%; stage D) undergoing mitral valve surgery because of severe symptoms (NYHA class III or IV) persisting despite guideline-directed medical therapy for HF.
C
Consider performing mitral valve surgery in patients with severe secondary MR (stages C and D) undergoing coronary artery bypass surgery for myocardial ischemia.
C

More topics in this section

  • Patients with AF (surgical ablation)

  • Patients with AF (anticoagulation)

  • Patients undergoing non-cardiac surgery

Follow-up and surveillance

Serial TTE: as per ACC/AHA 2021 guidelines, obtain TTEs every 6-12 months for surveillance of LV function (estimated by LVEF, LVEDD, and LVESD) and assessment of pulmonary artery pressure in asymptomatic patients with severe primary MR (stages B and C1).
B