Mitral regurgitation (MR) may present with dyspnoea, 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.
Colour 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.
The most common complications of surgical treatment are failure of repair, prosthetic valve stenosis, endocarditis, and mitral valve patient-prosthesis mismatch.
The mitral valve apparatus consists of anterior and posterior leaflets, chordae tendineae, anterolateral and posteromedial papillary muscles, and mitral annulus. Any aberrations of the mitral valve apparatus, due to mechanical, traumatic, infectious, degenerative, congenital, or metabolic causes, may lead to mitral regurgitation (MR).
Mild to moderate disease can be asymptomatic for many years; however, with progression of the disease, eccentric cardiac hypertrophy occurs, which leads to elongation of the myocardial fibres and increased left ventricular end-diastolic volume. Eventually, prolonged volume overload leads to left ventricular dysfunction and increased left ventricular end-systolic diameter.
History and exam
Key diagnostic factors
- presence of risk factors
- dyspnoea on exertion
- decreased exercise tolerance
- lower extremity oedema
- holosystolic murmur
Other diagnostic factors
- displaced point of maximal impulse
- paroxysmal nocturnal dyspnoea
- pulmonary closure is louder than aortic closure
- S3 heart sound
- diminished S1 heart sound
- mitral valve prolapse
- history of rheumatic heart disease
- infective endocarditis
- history of cardiac trauma
- history of myocardial infarction
- history of congenital heart disease
- history of ischaemic heart disease
- left ventricular systolic dysfunction
- hypertrophic cardiomyopathy
- anorectic/dopaminergic drugs
- elevated systolic blood pressure
1st investigations to order
- transthoracic echo
Investigations to consider
- flow convergence method or proximal isovelocity surface area
- colour Doppler flow
- transoesophageal echocardiogram
- cardiac catheterisation
- cardiac magnetic resonance imaging (CMR)
acute severe MR
chronic severe primary MR: asymptomatic
chronic primary MR: symptomatic
chronic severe secondary MR
Prakash P. Punjabi, FRCS, FESC, MS, MCh, FCCP, FFSTEd, Diplomate NBE
National Heart and Lung Institute
Imperial College London
Consultant Cardiothoracic Surgeon
Department of Cardiothoracic Surgery
Imperial College Healthcare NHS Trust
PPP is an author of references cited in this topic. PPP declares that he has no competing interests.
Dr Prakash P. Punjabi would like to gratefully acknowledge Dr Samir Kapadia and Dr Mehdi H. Shishehbor, previous contributors to this topic.
SK and MHS declare that they have no competing interests.
Matthew Czarny, MD
Assistant Professor of Medicine
Department of Cardiovascular Medicine
Johns Hopkins University School of Medicine
MC is a co-investigator for several clinical trials for Medtronic and Edwards Lifesciences involving transcatheter valve replacement or repair for the aortic, mitral, and tricuspid valves for which the Johns Hopkins University receives research funding. MC does not receive any direct or indirect support or remuneration for these roles. MC has received travel and accommodation from Abbott, the manufacturer of the MitraClip(TM) transcatheter edge-to-edge repair system, for attending training meetings.
- Acute coronary syndrome (ACS)
- Infective endocarditis
- Mitral stenosis
- 2020 ACC/AHA guideline for the management of patients with valvular heart disease
- 2021 ESC/EACTS guidelines for the management of valvular heart disease
Mitral regurgitation (severe)
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