Stages of secondary mitral regurgitation

Grade	Definition	Valve anatomy	Valve hemodynamics*	Associated cardiac findings	Symptoms
A	At risk of MR	Normal valve leaflets, chords, and annulus in a patient with coronary disease or cardiomyopathy	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.30 cm	Normal or mildly dilated LV size with fixed (infarction) or inducible (ischemia) regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
B	Progressive MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	ERO <0.40 cm²^¶ Regurgitant volume <60 mL Regurgitant fraction <50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
C	Asymptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	ERO ≥0.40 cm²^¶ Regurgitant volume ≥60 mL Regurgitant fraction ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	Symptoms due to coronary ischemia or HF may be present that respond to revascularization and appropriate medical therapy
D	Symptomatic severe MR	Regional wall motion abnormalities and/or LV dilation with severe tethering of mitral leaflet Annular dilation with severe loss of central coaptation of the mitral leaflets	ERO ≥0.40 cm²^¶ Regurgitant volume ≥60 mL Regurgitant fraction ≥50%	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction due to primary myocardial disease	HF symptoms due to MR persist even after revascularization and optimization of medical therapy Decreased exercise tolerance Exertional dyspnea

MR: mitral regurgitation; LA: left atrium; LV: left ventricle; HF: heart failure; ERO: effective regurgitant orifice; 2D: two-dimensional; TTE: transthoracic echocardiogram.

* Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. Categorization of MR severity as mild, moderate, or severe depends on the data quality and integration of these parameters in conjunction with other clinical evidence.

¶ The measurement of the proximal isovelocity surface area by 2D TTE in patients with secondary MR underestimates the true ERO because of the crescentic shape of the proximal convergence. Thus, the 2017 American Society of Echocardiography recommendations for native valvular regurgitation note that the criterion for severe secondary MR may be ≥0.30 cm² in the presence of an elliptical regurgitant orifice area.

Reproduced from: 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. Table used with the permission of Elsevier Inc. All rights reserved.

The content within this table is still current as of the 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease.

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Stages of secondary mitral regurgitation