Mitral regurgitation stages

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3]

Overview

The stage of mitral regurgitation (MR) can be estimated based on specific criteria for the valve anatomy, valve hemodynamics, associated cardiac findings, and symptoms. The stages of MR are the following: at risk of MR, progressive MR, asymptomatic severe MR, and symptomatic severe MR.[1]

Primary Mitral Regurgitation Stages

Shown below is a table depicting the stages of mitral regurgitation adapted from the 2014 AHA/ACC guidelines for management of valvular heart disease.[1]

Abbreviations: ERO: Effective regurgitant orifice; IE: Infective endocarditis; LA: Left atrium; LV: Left ventricle; LVEF: Left ventricular ejection fraction; LVESD: Left ventricular end systolic dimension MR: Mitral regurgitation; MVP: Mitral valve prolapse

Stage Definition Valve anatomy Valve hemodynamics Hemodynamic consequences Symptoms
A At risk of MR ❑ Mild MVP, normal coaptation
❑ Mild valve thickening and leaflet restriction
❑ No MR jet area or central jet area < 20% LA on doppler
❑ Small vena contracta <0.3 cm
Absent Absent
B Progressive MR ❑ Severe MVP, normal coaptation
❑ Rheumatic valve changes with leaflet restriction and loss of central coaptation due to
❑ Previous infective endocarditis
❑ Central jet area 20-40% LA or late systolic eccentric jet MR
❑ Vena contracta < 0.7 cm
❑ Regurgitant volume < 60 ml
❑ Regurgitant fraction <50 %
❑ ERO <0.40 cm2
❑ Angiographic grade 1 - 2+
❑ Mild LA enlargement
❑ Absent LV enlargement
❑ Normal pulmonary pressure
Absent
C Asymptomatic severe MR ❑ Severe MVP, flail leaflet
❑ Rheumatic valve changes with leaflet restriction,
loss of central coaptation
❑ Prior IE

❑ Thickening of leaflets in case of radiation heart disease

❑ Central jet area > 40% LA OR
holosystolic eccentric jet MR
❑ Vena contracta ≥ 0.7 cm
❑ Regurgitant volume ≥ 60 ml
❑ Regurgitant fraction ≥50 %
❑ ERO ≥0.40 cm2
❑ Angiographic grade 3 - 4+
❑ Moderate to severe LA enlargement
❑ LV enlargement
Pulmonary hypertension present at rest or with exercise
C1: LVEF > 60% and LVESD < 40 mm
C2: LVEF ≤ 60 % and LVESD ≥ 40 mm
Absent
D Symptomatic severe MR ❑ Severe MVP, flail leaflet
❑ Rheumatic valve changes with leaflet restriction,
loss of central coaptation
❑ Previous infective endocarditis

❑ Thickening of leaflets in case of radiation heart disease

❑ Central jet area >40% LA OR
holosystolic eccentric jet MR
❑ Vena contracta ≥ 0.7 cm
❑ Regurgitant volume ≥ 60 ml
❑ Regurgitant fraction ≥ 50 %
❑ ERO ≥0.40 cm2
❑ Angiographic grade 3 - 4+
❑ Moderate to severe LA enlargement
❑ LV enlargement
Pulmonary hypertension present
❑ Decreased exercise tolerance
Exertional dyspnea

Secondary Mitral Regurgitation Stages

Shown below is a table depicting the stages of mitral regurgitation adapted from the 2014 AHA/ACC guidelines for management of valvular heart disease.[1]

Abbreviations: CAD: Coronary artery disease; ERO: Effective regurgitant orifice; HF: Heart failure; IE: Infective endocarditis; LA: Left atrium; LV: Left ventricle; LVEF: Left ventricular ejection fraction; LVESD: Left ventricular end systolic dimension MR: Mitral regurgitation; MVP: Mitral valve prolapse

Stage Definition Valve anatomy Valve hemodynamics Hemodynamic consequences Symptoms
A At risk of MR ❑ The valve leaflets, chords, and annulus are normal in a patient with CAD or cardiomyopathy ❑ No MR jet area or central jet area < 20% LA on doppler
❑ Small vena contracta <0.3 cm
❑ The LV is normal or mildly dilated and is associated with a fixed or inducible Regional wall motion abnormalities

❑ LV dilatation and systolic dysfunction due to a primary myocardial disease

Possible symptoms of CAD or HF that are responsive to treatment or revascularization
B Progressive MR ❑ Mild tethering of the leaflets of the mitral valve with Regional wall motion abnormalities
❑ Annular dilatation and mild loss of coaptation of the mitral leaflets
❑ Regurgitant volume < 30 ml
❑ Regurgitant fraction <50 %
❑ ERO <0.20 cm2
❑ Regional wall motion abnormalities and LV systolic dysfunction

❑ LV dilatation and systolic dysfunction due to a primary myocardial disease

Possible symptoms of CAD or HF that are responsive to treatment or revascularization
C Asymptomatic severe MR ❑ Severe tethering of the leaflets of the mitral valve with LV dilatation and/or Regional wall motion abnormalities
❑ Annular dilatation and severe loss of coaptation of the mitral leaflets
❑ Regurgitant volume ≥30 ml
❑ Regurgitant fraction ≥50 %
❑ ERO ≥0.20 cm2
❑ Regional wall motion abnormalities and LV systolic dysfunction

LV dilatation and systolic dysfunction due to a primary myocardial disease

Possible symptoms of CAD or HF that are responsive to treatment or revascularization
D Symptomatic severe MR ❑ Severe tethering of the leaflets of the mitral valve with LV dilatation and/or Regional wall motion abnormalities
❑ Annular dilatation and severe loss of coaptation of the mitral leaflets
❑ Regurgitant volume ≥30 ml
❑ Regurgitant fraction ≥50 %
❑ ERO ≥0.20 cm2
❑ Regional wall motion abnormalities and LV systolic dysfunction

❑ LV dilatation and systolic dysfunction due to a primary myocardial disease

Symptoms of CAD or HF that are non responsive to treatment or revascularization
❑ Decreased exercise tolerance
Exertional dyspnea

References

  1. 1.0 1.1 1.2 Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines". Circulation. doi:10.1161/CIR.0000000000000029. PMID 24589852.

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