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Mitral regurgitation

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.
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).
The prevalence of MR in the US is estimated at 1,700 patients per 100,000 population.
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.
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/EACTS 2021), and the European Society of Cardiology (ESC 2021).


1.Diagnostic investigations

Transthoracic echocardiogram: 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.
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  • TEE

  • Exercise stress testing

  • Cardiac MRI

  • Cardiac biomarkers

2.Diagnostic procedures

Cardiac catheterization: consider performing cardiac catheterization in patients with primary MR (stages B and C) and symptoms likely attributable to MR.

3.Medical management

Management of systolic dysfunction
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.
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.

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  • Antihypertensive therapy

  • Vasodilator therapy

4.Perioperative care

Intraoperative imaging
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.
Obtain intraprocedural TEE for guidance in patients with chronic secondary MR undergoing transcatheter mitral valve intervention.

5.Surgical interventions

Mitral valve repair, primary mitral regurgitation, symptomatic patients, AHA/ACC: perform mitral valve intervention in symptomatic patients with severe primary MR (stage D), irrespective of LV systolic function.
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  • Mitral valve repair, primary MR (asymptomatic patients)

  • Mitral valve repair, secondary MR

6.Specific circumstances

Patients with coronary artery disease
As per ACC 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.
Consider performing mitral valve surgery in patients with severe secondary MR (stages C and D) undergoing coronary artery bypass surgery for myocardial ischemia.

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  • Patients with AF (surgical ablation)

  • Patients with AF (anticoagulation)

  • Patients undergoing non-cardiac surgery

7.Follow-up and surveillance

Serial transthoracic echocardiogram: 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).