Parameters of Mitral Regurgitation on Echocardiography

  • Mitral regurgitation

    Mild
    Moderate
    Severe
    Structural
    Mitral valve morphology None or mild leaflet abnormality

    (e.g., mild thickening, calcifications or prolapse, mild tenting)

    		 Moderate leaflet abnormality or moderate tenting Severe valve lesions

    (primary: flail leaflet, ruptured papillary muscle, severe retraction, large perforation; secondary: severe tenting, poor leaflet coaptation)
    Left ventricle (Size)1 Usually normal

    (LVEDV =150ml male, =106ml female)

    		 Normal or mild dilated Dilated2

    (LVEDV >150ml male, >106ml female)
    Left atrium (Size)1 Usually normal

    (LA volume =34ml/m2)

    		 Normal or mild dilated Dilated2
    Qualitative doppler
    RegJetarea

    Regurgitation jet area.
    (Nyquist limit 50-70cm/s)

    		 Small, central, narrow, often brief

    (RegJet/LA area <20%)

    		 Variable Large central jet

    (RegJet/LA area >50%) or eccentric wall-impinging jet of variable size
    Flow convergence (PISAr)

    (Nyquist limit 30-40cm/s)

    		 Not visible, transient or small

    (PISAr <0,3cm)

    		 Intermediate in size and duration Large throughout systole

    (PISAr =1cm)
    Regurgitant jet

    (CW doppler)

    		 Faint/ partial/ parabolic Dense but partial or parabolic Holosystolic/ dense/ triangular
    Semiquantitative
    VCW (cm)

    Vena contracta width

    		 <0,3cm 0,3 - 0,7cm >0,7cm (>0,8cm)3
    Pulmonary vein flow4 Systolic dominance (may be blunted in LV dysfunction or AF) Normal or systolic blunting Minimal to no systolic flow/ systolic flow reversal
    Mitral inflow5 A wave dominant

    (A wave > E wave)

    		 Variable E wave dominant

    (E wave >1,2m/s)
    Quantitative6
    Grade I
    Grade II
    Grade III
    Grade IV
    EROA (cm2)

    Effective regurgitant orifice area

    		 <0,2 0,2 - 0,3 0,3 - 0,39 >0,4
    RegVol (ml)

    Regurgitant volume of mitral regurgitation

    		 <30 30 - 44 45 - 59 >60
    RF (%)

    Regurgitant fraction of mitral valve

    		 <30 30 - 39 40 - 49 >50

    Bolded qualitative and semiquantitative signs are considered specific for their MR grade. All parameters have limitations, and an integrated approach must be used that weighs the strength of each echocardiographic measurement. All signs and measures should be interpreted in an individualized manner that accounts for body size, sex, and all other patient characteristics.

    (1) This pertains mostly to patients with primary. (2) LV and LA can be within the “normal” range for patients with acute severe MR or with chronic severe MR who have small body size, particularly women, or with small LV size preceding the occurrence of MR. (3) For average between apical two- and four-chamber views (Biplane). (4) Influenced by many other factors (LV diastolic function, atrial fibrillation, LA pressure). (5) Most valid in patients >50 years old and is influenced by other causes of elevated LA pressure. (6) Discrepancies among EROA, RF, and RegVol may arise in the setting of low or high flow states. Quantitative parameters can help subclassify the moderate regurgitation group.

    ASE Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation (2017)