Echocardiographic assessment of mitral regurgitation

  • Nobuyuki KagiyamaEmail author
  • Sirish Shrestha
Special Feature: Review Article Echocardiographic management of valvular heart disease


Mitral regurgitation (MR) is one of the most frequent indications for valve surgery in developed countries, and echocardiographic assessment is an essential tool to evaluate its etiologies, severity, and therapeutic indications. The mitral valve apparatus is a complex structure composed of several parts: apart from the mitral valve leaflets and annulus, it also includes the chordae tendineae, papillary muscles, and left ventricular (LV) wall. MR can be caused not only by organic changes of the mitral valve leaflets or chordae (primary MR) but also by extreme mitral annular enlargement or mitral leaflet tethering due to displacement and malfunction of papillary muscles and LV wall (secondary MR). In secondary MR with LV dysfunction, a milder degree of MR can be associated with adverse outcomes compared with primary MR. Grading the severity is the first step in evaluation of indication for surgical/transcatheter interventions. As such, there are several techniques to assess the severity of MR using echocardiography. However, none of the techniques is reliable enough by itself, and it is always recommended to integrate multiple methods. In cases where echocardiographic assessment of MR severity is inconclusive, magnetic resonance may be helpful. In addition to the severity, anatomical information, such as localization in primary MR due to mitral valve prolapse and LV size in secondary MR due to LV dilatation/dysfunction, is an important concern in presurgical echocardiography. Transesophageal echocardiography and three-dimensional echocardiography are key techniques for anatomical evaluation including mitral valve and LV volumes. In transcatheter intervention for MR, echocardiography plays a pivotal role as a guide for procedures and endpoints. In this review article, the authors provide a comprehensive summary of current standards of echocardiographic assessment of MR.


Echocardiography Three-dimensional (3D) echocardiography Mitral regurgitation Mitral valve prolapse Mitral valve repair Transcatheter mitral valve repair 


Compliance with ethical standards

Conflict of interest

The authors declare that there are no conflicts of interest.

Ethical statements

There are no ethical issues to disclose (the article is not original research).


  1. 1.
    Shimizu H, Endo S, Natsugoe S, et al. Thoracic and cardiovascular surgery in japan in 2016: annual report by the japanese association for thoracic surgery. Gen Thorac Cardiovasc Surg. 2019;67:377–411.CrossRefPubMedGoogle Scholar
  2. 2.
    Adams DH, Rosenhek R, Falk V. Degenerative mitral valve regurgitation: best practice revolution. Eur Heart J. 2010;31:1958–66.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    O’Gara PT, Grayburn PA, Badhwar V, et al. 2017 acc expert consensus decision pathway on the management of mitral regurgitation: a report of the american college of cardiology task force on expert consensus decision pathways. J Am Coll Cardiol. 2017;70:2421–49.CrossRefPubMedGoogle Scholar
  4. 4.
    Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2017;30:303–71.CrossRefPubMedGoogle Scholar
  5. 5.
    Nishino S, Watanabe N, Kimura T, et al. Acute versus chronic ischemic mitral regurgitation: an echocardiographic study of anatomy and physiology. Circ Cardiovasc Imaging. 2018;11:e007028.CrossRefPubMedGoogle Scholar
  6. 6.
    Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative doppler assessment. Circulation. 2001;103:1759–64.CrossRefPubMedGoogle Scholar
  7. 7.
    Hepner AD, Ahmadi-Kashani M, Movahed MR. The prevalence of mitral valve prolapse in patients undergoing echocardiography for clinical reason. Int J Cardiol. 2007;123:55–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Theal M, Sleik K, Anand S, et al. Prevalence of mitral valve prolapse in ethnic groups. Can J Cardiol. 2004;20:511–5.PubMedGoogle Scholar
  9. 9.
    Kagiyama N, Toki M, Hayashida A, et al. Prolapse volume to prolapse height ratio for differentiating barlow’s disease from fibroelastic deficiency. Circ J. 2017;81:1730–5.CrossRefPubMedGoogle Scholar
  10. 10.
    Barlow JB, Pocock WA. The significance of late systolic murmurs and mid-late systolic clicks. Md State Med J. 1963;12:76–7.PubMedGoogle Scholar
  11. 11.
    Carpentier A, Chauvaud S, Fabiani JN, et al. Reconstructive surgery of mitral valve incompetence: ten-year appraisal. J Thorac Cardiovasc Surg. 1980;79:338–48.PubMedGoogle Scholar
  12. 12.
    Otsuji Y, Handschumacher MD, Schwammenthal E, et al. Insights from three-dimensional echocardiography into the mechanism of functional mitral regurgitation: direct in vivo demonstration of altered leaflet tethering geometry. Circulation. 1997;96:1999–2008.CrossRefPubMedGoogle Scholar
  13. 13.
    Otsuji Y, Handschumacher MD, Liel-Cohen N, et al. Mechanism of ischemic mitral regurgitation with segmental left ventricular dysfunction: three-dimensional echocardiographic studies in models of acute and chronic progressive regurgitation. J Am Coll Cardiol. 2001;37:641–8.CrossRefPubMedGoogle Scholar
  14. 14.
    Nishino S, Watanabe N, Kimura T, et al. The course of ischemic mitral regurgitation in acute myocardial infarction after primary percutaneous coronary intervention: from emergency room to long-term follow-up. Circ Cardiovasc Imaging. 2016;9:e004841.CrossRefPubMedGoogle Scholar
  15. 15.
    Gertz ZM, Raina A, Saghy L, et al. Evidence of atrial functional mitral regurgitation due to atrial fibrillation: reversal with arrhythmia control. J Am Coll Cardiol. 2011;58:1474–81.CrossRefPubMedGoogle Scholar
  16. 16.
    Kagiyama N, Hayashida A, Toki M, et al. Insufficient leaflet remodeling in patients with atrial fibrillation: association with the severity of mitral regurgitation. Circ Cardiovasc Imaging. 2017;10:e005451.CrossRefPubMedGoogle Scholar
  17. 17.
    Kagiyama N, Mondillo S, Yoshida K, et al. Subtypes of atrial functional mitral regurgitation: imaging insights into their mechanisms and therapeutic implications. J Am Coll Cardiol Img. 2019. Scholar
  18. 18.
    Baumgartner H, Falk V, Bax JJ, et al. 2017 esc/eacts guidelines for the management of valvular heart disease. Eur Heart J. 2017;38:2739–91.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Nishimura RA, Otto CM, Bonow RO, Carabello BA, et al. 2014 aha/acc guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart association task force on practice guidelines. Circulation. 2014;129:e521–643.PubMedGoogle Scholar
  20. 20.
    Thompson CR, Buller CE, Sleeper LA, et al. Cardiogenic shock due to acute severe mitral regurgitation complicating acute myocardial infarction: a report from the shock trial registry. J Am Coll Cardiol. 2000;36:1104–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Smyllie JH, Sutherland GR, Geuskens R, et al. Doppler color flow mapping in the diagnosis of ventricular septal rupture and acute mitral regurgitation after myocardial infarction. J Am Coll Cardiol. 1990;15:1449–55.CrossRefPubMedGoogle Scholar
  22. 22.
    Roberts WC, Braunwald E, Morrow AG. Acute severe mitral regurgitation secondary to ruptured chordae tendineae: clinical, hemodynamic, and pathologic considerations. Circulation. 1966;33:58–70.CrossRefPubMedGoogle Scholar
  23. 23.
    Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med. 2005;352:875–83.CrossRefPubMedGoogle Scholar
  24. 24.
    Devereux RB, Kramer-Fox R, Shear MK, et al. Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic, and prognostic considerations. Am Heart J. 1987;113:1265–80.CrossRefPubMedGoogle Scholar
  25. 25.
    Lancellotti P, Moura L, Pierard LA, Reviewers: D, Sicari R, Vahanian A, Roelandt JRTC., et al. European association of echocardiography recommendations for the assessment of valvular regurgitation. Part 2: Mitral and tricuspid regurgitation (native valve disease). Eur Heart J Cardiovasc Imaging. 2010;11:307–32.Google Scholar
  26. 26.
    Hall Shelley A, Brickner ME, Willett DuWayne L, et al. Assessment of mitral regurgitation severity by doppler color flow mapping of the vena contracta. Circulation. 1997;95:636–42.CrossRefGoogle Scholar
  27. 27.
    Baumgartner H, Schima H, Kühn P. Value and limitations of proximal jet dimensions for the quantitation of valvular regurgitation: an in vitro study using doppler flow imaging. J Am Soc Echocardiogr. 1991;4:57–66.CrossRefPubMedGoogle Scholar
  28. 28.
    Enriquez-Sarano M, Seward JB, Bailey KR, et al. Effective regurgitant orifice area: a noninvasive doppler development of an old hemodynamic concept. J Am Coll Cardiol. 1994;23:443–51.CrossRefPubMedGoogle Scholar
  29. 29.
    Enriquez-Sarano M, Bailey KR, Seward JB. Quantitative doppler assessment of valvular regurgitation. Circulation. 1993;87:841–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Blumlein S, Bouchard A, Schiller NB, et al. Quantitation of mitral regurgitation by doppler echocardiography. Circulation. 1986;74:306–14.CrossRefPubMedGoogle Scholar
  31. 31.
    Dujardin Karl S, Enriquez-Sarano M, Bailey Kent R, et al. Grading of mitral regurgitation by quantitative doppler echocardiography. Circulation. 1997;96:3409–15.CrossRefGoogle Scholar
  32. 32.
    Uretsky S, Gillam L, Lang R, et al. Discordance between echocardiography and mri in the assessment of mitral regurgitation severity: a prospective multicenter trial. J Am Coll Cardiol. 2015;65:1078–88.CrossRefPubMedGoogle Scholar
  33. 33.
    Uretsky S, Aldaia L, Marcoff L, et al. The effect of systolic variation of mitral regurgitation on discordance between noninvasive imaging modalities. J Am Coll Cardiol Img. 2019. Scholar
  34. 34.
    Tsang W, Weinert L, Sugeng L, et al. The value of three-dimensional echocardiography derived mitral valve parametric maps and the role of experience in the diagnosis of pathology. J Am Soc Echocardiogr. 2011;24:860–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Chandra S, Salgo IS, Sugeng L, Weinert L, Tsang W, Takeuchi M, Spencer KT, O’Connor A, Cardinale M, Settlemier S, Mor-Avi V, Lang RM. Characterization of degenerative mitral valve disease using morphologic analysis of real-time three-dimensional echocardiographic images: objective insight into complexity and planning of mitral valve repair. Circ Cardiovasc Imaging. 2011;4:24–32.CrossRefPubMedGoogle Scholar
  36. 36.
    Tsang W, Salgo IS, Medvedofsky D, et al. Transthoracic 3d echocardiographic left heart chamber quantification using an automated adaptive analytics algorithm. JACC Cardiovasc Imaging. 2016;9:769–82.CrossRefPubMedGoogle Scholar
  37. 37.
    Kagiyama N, Toki M, Hara M, et al. Efficacy and accuracy of novel automated mitral valve quantification: three-dimensional transesophageal echocardiographic study. Echocardiography. 2016;33:756–63.CrossRefPubMedGoogle Scholar
  38. 38.
    Toki M, Kagiyama N, Maeda M, et al. Novel automated left heart chamber quantification software is useful for both beginners and experts: three-dimensional transthoracic echocardiographic study. J Am Soc Echocardiogr. 2017;30:B46.Google Scholar
  39. 39.
    Goebel B, Heck R, Hamadanchi A, et al. Vena contracta area for severity grading in functional and degenerative mitral regurgitation: a transoesophageal 3d colour doppler analysis in 500 patients. Eur Heart J Cardiovasc Imaging. 2018;19:639–46.CrossRefPubMedGoogle Scholar
  40. 40.
    Schmidt FP, Gniewosz T, Jabs A, et al. Usefulness of 3d-pisa as compared to guideline endorsed parameters for mitral regurgitation quantification. Int J Cardiovasc Imaging. 2014;30:1501–8.CrossRefPubMedGoogle Scholar
  41. 41.
    Nishimura RA, Otto CM, Bonow RO, et al. 2017 aha/acc focused update of the 2014 aha/acc guideline for the management of patients with valvular heart disease: a report of the american college of cardiology/american heart association task force on clinical practice guidelines. J Am Coll Cardiol. 2017;70:252–89.CrossRefPubMedGoogle Scholar
  42. 42.
    Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of survival after surgical correction of organic mitral regurgitation. Circulation. 1994;90:830–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Badhwar V, Peterson ED, Jacobs JP, et al. Longitudinal outcome of isolated mitral repair in older patients: Results from 14,604 procedures performed from 1991 to 2007. Ann Thorac Surg. 2012;94:1870–7 discussion 1877-9.CrossRefPubMedGoogle Scholar
  44. 44.
    Le Tourneau T, Richardson M, Juthier F, et al. Echocardiography predictors and prognostic value of pulmonary artery systolic pressure in chronic organic mitral regurgitation. Heart. 2010;96:1311–7.CrossRefPubMedGoogle Scholar
  45. 45.
    Mentias A, Naji P, Gillinov AM, et al. Strain echocardiography and functional capacity in asymptomatic primary mitral regurgitation with preserved ejection fraction. J Am Coll Cardiol. 2016;68:1974–86.CrossRefPubMedGoogle Scholar
  46. 46.
    Lancellotti P, Stainier PY, Lebois F, et al. Effect of dynamic left ventricular dyssynchrony on dynamic mitral regurgitation in patients with heart failure due to coronary artery disease. Am J Cardiol. 2005;96:1304–7.CrossRefPubMedGoogle Scholar
  47. 47.
    Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantitative exercise doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377–82.PubMedGoogle Scholar
  48. 48.
    Lancellotti P, Troisfontaines P, Toussaint AC, et al. Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction. Circulation. 2003;108:1713–7.CrossRefPubMedGoogle Scholar
  49. 49.
    Magne J, Lancellotti P, Pierard LA. Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation. 2010;122:33–41.CrossRefPubMedGoogle Scholar
  50. 50.
    Wunderlich NC, Siegel RJ. Peri-interventional echo assessment for the mitraclip procedure. Eur Heart J Cardiovasc Imaging. 2013;14:935–49.CrossRefPubMedGoogle Scholar
  51. 51.
    Zoghbi WA, Asch FM, Bruce C, et al. Guidelines for the evaluation of valvular regurgitation after percutaneous valve repair or replacement: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular angiography and interventions, Japanese society of echocardiography, and society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2019;32:431–75.CrossRefPubMedGoogle Scholar
  52. 52.
    Komeda M, Koyama Y, Fukaya S, et al. Papillary heads “optimization” in repairing functional mitral regurgitation. J Thorac Cardiovasc Surg. 2012;144:1262–4.CrossRefPubMedGoogle Scholar
  53. 53.
    Matsui Y, Shingu Y, Wakasa S, et al. Papillary muscle tugging approximation for functional mitral regurgitation. Ann Thorac Surg. 2019;107:e427–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med. 2013;370:23–32.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Shingu Y, Yamada S, Ooka T, et al. Papillary muscle suspension concomitant with approximation for functional mitral regurgitation. Circ J. 2009;73:2061–7.CrossRefPubMedGoogle Scholar
  56. 56.
    Arai H, Itoh F, Someya T, et al. New surgical procedure for ischemic/functional mitral regurgitation: mitral complex remodeling. Ann Thorac Surg. 2008;85:1820–2.CrossRefPubMedGoogle Scholar
  57. 57.
    Stone GW, Lindenfeld J, Abraham WT, et al. Transcatheter mitral-valve repair in patients with heart failure. N Engl J Med. 2018;379:2307–18.CrossRefPubMedGoogle Scholar
  58. 58.
    Obadia JF, Messika-Zeitoun D, Leurent G, et al. Percutaneous repair or medical treatment for secondary mitral regurgitation. N Engl J Med. 2018;379:2297–306.CrossRefPubMedGoogle Scholar
  59. 59.
    Pibarot P, Delgado V, Bax JJ. Mitra-fr vs. Coapt: lessons from two trials with diametrically opposed results. Eur Heart J Cardiovascular Imaging. 2019;20:620–4.CrossRefGoogle Scholar

Copyright information

© The Japan Society of Ultrasonics in Medicine 2019

Authors and Affiliations

  1. 1.West Virginia University Heart and Vascular InstituteMorgantownUSA

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