Mitral regurgitation

Last reviewed: 11 May 2023
Last updated: 12 Apr 2022



History and exam

Key diagnostic factors

  • dyspnea on exertion
  • decreased exercise tolerance
  • lower extremity edema
  • holosystolic murmur
More key diagnostic factors

Other diagnostic factors

  • fatigue
  • displaced point of maximal impulse
  • orthopnea
  • paroxysmal nocturnal dyspnea
  • palpitations
  • diaphoresis
  • pulmonary closure is louder than aortic closure
  • S3 heart sound
  • diminished S1 heart sound
Other diagnostic factors

Risk factors

  • 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 ischemic heart disease
  • left ventricular systolic dysfunction
  • hypertrophic cardiomyopathy
  • anorectic/dopaminergic drugs
  • elevated systolic blood pressure
More risk factors

Diagnostic investigations

1st investigations to order

  • transthoracic echo
  • ECG
More 1st investigations to order

Investigations to consider

  • flow convergence method or proximal isovelocity surface area
  • color Doppler flow
  • transesophageal echocardiogram
  • cardiac catheterization
  • cardiac magnetic resonance imaging (CMR)
More investigations to consider

Treatment algorithm


acute severe MR


chronic severe primary MR: asymptomatic

chronic severe 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

Hammersmith Hospital

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.

Peer reviewers

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.

  • Mitral regurgitation images
  • Differentials

    • Acute coronary syndrome (ACS)
    • Infective endocarditis
    • Mitral stenosis
    More Differentials
  • Guidelines

    • 2020 ACC/AHA guideline for the management of patients with valvular heart disease
    • 2021 ESC/EACTS guidelines for the management of valvular heart disease
    More Guidelines
  • Videos

    Mitral regurgitation (severe)

    Third heart sound gallop

    More videos
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