Echocardiographic assessment of mitral regurgitation
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.
KeywordsEchocardiography 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.
There are no ethical issues to disclose (the article is not original research).
- 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
- 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
- 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
- 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
- 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
- 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
- 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