Table 14

Stages of Secondary MR

GradeDefinitionValve AnatomyValve HemodynamicsAssociated Cardiac FindingsSymptoms
AAt risk of MR
  • Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy

  • No MR jet or small central jet area <20% LA on Doppler

  • Small vena contracta <0.30 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 due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy

BProgressive MR
  • Regional wall motion abnormalities with mild tethering of mitral leaflet

  • Annular dilation with mild loss of central coaptation of the mitral leaflets

  • ERO <0.20 cm2

  • Regurgitant volume <30 mL

  • Regurgitant fraction <50%

  • Regional wall motion abnormalities with reduced LV systolic function

  • LV dilation and systolic dysfunction due to primary myocardial disease

  • Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy

CAsymptomatic 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 ≥0.20 cm2

  • Regurgitant volume ≥30 mL

  • Regurgitant fraction ≥50%

  • Regional wall motion abnormalities with reduced LV systolic function

  • LV dilation and systolic dysfunction due to primary myocardial disease

  • Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy

DSymptomatic 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 ≥0.20 cm2

  • Regurgitant volume ≥30 mL

  • Regurgitant fraction ≥50%

  • Regional wall motion abnormalities with reduced LV systolic function

  • LV dilation and systolic dysfunction due to primary myocardial disease

  • HF symptoms due to MR persist even after revascularization and optimization of medical therapy

  • Decreased exercise tolerance

  • Exertional dyspnea

2D indicates 2-dimensional; ERO, effective regurgitant orifice; HF, heart failure; LA, left atrium; LV, left ventricular; MR, mitral regurgitation; and TTE, transthoracic echocardiogram.

  • 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 due to the crescentic shape of the proximal convergence.