Highlights & Basics
- Mitral regurgitation (MR) may present with dyspnea, usually on exertion, palpitations, and/or decreased exercise tolerance.
- Typically, presents as a holosystolic blowing murmur at the apex, radiating to the axilla.
- Transthoracic echo is the diagnostic test of choice in identifying presence, severity, and mechanism of MR.
- Color Doppler flow and continuous-wave Doppler studies can assess severity of regurgitation, left ventricular dimensions, size and function of the right ventricle, and pulmonary artery systolic pressure.
- Management options include surgical repair or replacement and transcatheter mitral valve repair; the risks and benefits of interventional options should be individually evaluated for each patient.
Quick Reference
History & Exam
Key Factors
Other Factors
Diagnostics Tests
Treatment Options
Definition
Epidemiology
Etiology
Pathophysiology
Images
Mitral valve P2 leaflet prolapse: 3D view
Mitral valve P2 leaflet prolapse: 2D view
Posterior mitral valve prolapse on M-mode echo
Parasternal long-axis view showing posterior mitral leaflet prolapse
Apical 3-chamber view of hypertrophic cardiomyopathy with systolic anterior motion
Apical 4-chamber view of flail posterior mitral leaflet
Prosthetic mitral valve with intermittent mitral regurgitation
Prosthetic mitral valve with intermittent mitral regurgitation
Apical 4-chamber view of 1-2+ posteriorly directed mitral regurgitation
Apical 4-chamber view of 4+ (severe) mitral regurgitation and a large proximal isovelocity surface area
Apical 4-chamber view of severe MR with proximal isovelocity surface area
Citations
De Bonis M, Al-Attar N, Antunes M, et al. Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease. Eur Heart J. 2016 Jan 7;37(2):133-9.[Abstract][Full Text]
Otto CM, Nishimura RA, Bonow RO, et al. 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. 2021 Feb 2;143(5):e72-227.[Abstract][Full Text]
Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022 Feb 12;43(7):561-632.[Abstract][Full Text]
Bonow RO, O'Gara PT, Adams DH, et al. 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020 May 5;75(17):2236-70.[Abstract][Full Text]
1. De Bonis M, Al-Attar N, Antunes M, et al. Surgical and interventional management of mitral valve regurgitation: a position statement from the European Society of Cardiology Working Groups on Cardiovascular Surgery and Valvular Heart Disease. Eur Heart J. 2016 Jan 7;37(2):133-9.[Abstract][Full Text]
2. Troubil M, Lonsky V, Gwozdziewicz M, et al. Persistent and recurrent ischemic mitral regurgitation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2010 Jun;154(2):141-5.[Abstract][Full Text]
3. Otto CM. Clinical practice: evaluation and management of chronic mitral regurgitation. N Engl J Med. 2001 Sep 6;345(10):740-6.[Abstract]
4. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. 1999 Jul 1;341(1):1-7.[Abstract][Full Text]
5. Avierinos JF, Gersh BJ, Melton LJ 3rd, et al. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. 2002 Sep 10;106(11):1355-61.[Abstract][Full Text]
6. Nazarzadeh M, Pinho-Gomes AC, Smith Byrne K, et al. Systolic blood pressure and risk of valvular heart disease: a Mendelian randomization study. JAMA Cardiol. 2019 Aug 1;4(8):788-95.[Abstract][Full Text]
7. Rahimi K, Mohseni H, Otto CM, et al. Elevated blood pressure and risk of mitral regurgitation: a longitudinal cohort study of 5.5 million United Kingdom adults. PLoS Med. 2017 Oct;14(10):e1002404.[Abstract][Full Text]
8. Otto CM, Nishimura RA, Bonow RO, et al. 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. 2021 Feb 2;143(5):e72-227.[Abstract][Full Text]
9. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J. 2022 Feb 12;43(7):561-632.[Abstract][Full Text]
10. Lancellotti P, Moura L, Pierard LA, et al; European Association of Echocardiography. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr. 2010 May;11(4):307-32.[Abstract]
11. Hiemstra YL, Tomsic A, van Wijngaarden SE, et al. Prognostic value of global longitudinal strain and etiology after surgery for primary mitral regurgitation. JACC Cardiovasc Imaging. 2020 Feb;13(2 pt 2):577-85.[Abstract][Full Text]
12. Kim HM, Cho GY, Hwang IC, et al. Myocardial strain in prediction of outcomes after surgery for severe mitral regurgitation. JACC Cardiovasc Imaging. 2018 Sep;11(9):1235-44.[Abstract][Full Text]
13. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005 Mar 3;352(9):875-83.[Abstract][Full Text]
14. Cosgrove DM, Stewart WJ. Mitral valvuloplasty. Curr Probl Cardiol. 1989 Jul;14(7):359-415.[Abstract]
15. Stewart WJ, Currie PJ, Salcedo EE, et al. Evaluation of mitral leaflet motion by echocardiography and jet direction by Doppler color flow mapping to determine the mechanisms of mitral regurgitation. J Am Coll Cardiol. 1992 Nov 15;20(6):1353-61.[Abstract][Full Text]
16. Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr. 2003 Jul;16(7):777-802.[Abstract]
17. Pu M, Griffin BP, Vandervoort PM, et al. The value of assessing pulmonary venous flow velocity for predicting severity of mitral regurgitation: a quantitative assessment integrating left ventricular function. J Am Soc Echocardiogr. 1999 Sep;12(9):736-43.[Abstract]
18. Pu M, Vandervoort PM, Griffin BP, et al. Quantification of mitral regurgitation by the proximal convergence method using transesophageal echocardiography: clinical validation of a geometric correction for proximal flow constraint. Circulation. 1995 Oct 15;92(8):2169-77.[Abstract][Full Text]
19. Kitkungvan D, Nabi F, Kim RJ, et al. Myocardial fibrosis in patients with primary mitral regurgitation with and without prolapse. J Am Coll Cardiol. 2018 Aug 21;72(8):823-34.[Abstract][Full Text]
20. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2021 Nov 30;144(22):e368-e454.[Abstract][Full Text]
21. National Institute for Health and Care Excellence. Heart valve disease presenting in adults: investigation and management. Nov 2021 [internet publication].[Full Text]
22. Murphy MO, Rao C, Punjabi PP, et al. In patients undergoing mitral surgery for ischaemic mitral regurgitation is it preferable to repair or replace the mitral valve? Interact Cardiovasc Thorac Surg. 2011 Feb;12(2):218-27.[Abstract][Full Text]
23. Sá MP, Ferraz PE, Escobar RR, et al. Preservation versus non-preservation of mitral valve apparatus during mitral valve replacement: a meta-analysis of 3835 patients. Interact Cardiovasc Thorac Surg. 2012 Dec;15(6):1033-9.[Abstract][Full Text]
24. Bonow RO, O'Gara PT, Adams DH, et al. 2020 focused update of the 2017 ACC expert consensus decision pathway on the management of mitral regurgitation: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020 May 5;75(17):2236-70.[Abstract][Full Text]
25. Hu X, Zhao Q. Systematic evaluation of the flexible and rigid annuloplasty ring after mitral valve repair for mitral regurgitation. Eur J Cardiothorac Surg. 2011 Aug;40(2):480-7.[Abstract][Full Text]
26. Keeling D, Baglin T, Tait C, et al; British Committee for Standards in Haematology. Guidelines on oral anticoagulation with warfarin - fourth edition. Br J Haematol. 2011 Aug;154(3):311-24.[Abstract][Full Text]
27. Habib G, Lancellotti P, Antunes MJ, et al. 2015 ESC guidelines for the management of infective endocarditis. Eur Heart J. 2015 Nov 21;36(44):3075-28.[Abstract][Full Text]
28. Chan KM, Punjabi PP, Flather M, et al; RIME Investigators. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the randomized ischemic mitral evaluation (RIME) trial. Circulation. 2012 Nov 20;126(21):2502-10.[Abstract][Full Text]
