Stages of primary MR

Grade	Definition	Valve anatomy	Valve hemodynamics*	Hemodynamic consequences	Symptoms
A	At risk of MR	Mild mitral valve prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.3 cm	None	None
B	Progressive MR	Severe mitral valve prolapse with normal coaptation Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE	Central jet MR 20 to 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 No LV enlargement Normal pulmonary pressure	None
C	Asymptomatic severe MR	Severe mitral valve prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >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 to 4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension may be present at rest or with exercise C1: LVEF >60% and LVESD <40 mm C2: LVEF ≤60% and LVESD ≥40 mm	None
D	Symptomatic severe MR	Severe mitral valve prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR >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 to 4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present	Decreased exercise tolerance Exertional dyspnea

ERO: effective regurgitant orifice; IE: infective endocarditis; LA: left atrium/atrial; LV: left ventricular; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic dimension; MR: mitral regurgitation.
* 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 data quality and integration of these parameters in conjunction with other clinical evidence.

Reproduced from: Nishimura RA, Otto CM, Bonow RO, 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. J Am Coll Cardiol 2014; 63:e57. 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 primary MR