Diagnostic Considerations

It is essential that clinicians identify mitral regurgitation (MR), define its cause (including whether the MR is primary or secondary) and the Carpentier classification of leaflet motion, assessing the MR severity, make treatment decisions with the heart valve team, and follow-up with clinical cardiology and the primary care provider.^{[11, 12]}

Calcified aortic stenosis also produces a prominent murmur at the apex (Gallavardin phenomenon) and may be confused with mitral valve regurgitation.

Tricuspid regurgitation also causes a holosystolic murmur. However, it is located at the left lower sternal border rather than the apex, it does not radiate to the axilla, and it increases in intensity with inspiration, whereas MR does not.

A ventricular septal defect produces a harsh holosystolic murmur at the lower left sternal border, but it generally radiates to the right of the sternum rather than the axilla and typically has a thrill.

Differential Diagnoses

Workup

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Media Gallery

Transthoracic echocardiogram demonstrating severe mitral regurgitation with heavily calcified mitral valve and prolapse of the posterior leaflet into the left atrium.
Transesophageal echocardiogram demonstrating prolapse of both mitral valve leaflets during systole.
Transthoracic echocardiogram demonstrating bioprosthetic mitral valve dehiscence with paravalvular regurgitation.

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Table 1. Stages of Progression of Chronic Mitral Regurgitation

Table 1. Stages of Progression of Chronic Mitral Regurgitation

Stage	Valve Anatomy	Valve Hemodynamics*	Hemodynamic Consequences	Symptoms
A: Primary MR	Mild MV prolapse with normal coaptation Mild valve thickening and leaflet restriction	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	None	None
A: Secondary MR	Normal valve leaflets, chords and annulus in patient with CAD or cardiomyopathy	No MR jet or small central jet area < 20% LA Small vena contracta < 0.3 cm	Normal or mildly dilated LV with infarction or ischemia regional wall motion abnormalities Primary myocardial disease with LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
B: Primary MR	Severe MV prolapse with normal coaptation Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE	Central jet MR area 20-40% LA or late systolic eccentric jet MR Vena contracts < 0.7 cm Regurgitant volume < 60 mL Regurgitant fraction < 50% ERO < 0.40 cm ² Angiographic grade 1-2+	Mild LA enlargement No LV enlargement Normal Pulmonary pressure	None
B: Secondary MR	Regional wall motion abnormalities with mild tethering of mitral leaflet Annular dilation with mild loss of central coaptation of the mitral leaflets	Regurgitant volume < 30 mL Regurgitant fraction < 50% ERO < 0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
C: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate to severe LA enlargement LV enlargement Pulmonary hypertension may be present Stage C1: LVEF >60% and LVESD < 40 mm Stage C2: LVEF ≤60% and LVESD ≥40 mm	None
C: Secondary 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	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	Symptoms of coronary ischemia or HF that respond to revascularization and medical therapy
D: Primary MR	Severe MV prolapse with loss of coaptation or flail leaflet Rheumatic valve changes, leaflet restriction, and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease	Central jet MR area >40% LA or holosystolic eccentric jet MR Vena contracta ≥0.7 cm Regurgitant volume ≥60 mL Regurgitant fraction ≥50% ERO ≥0.40 cm ² Angiographic grade 3-4+	Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present	Decreased exercise tolerance Exertional dyspnea
D: Secondary 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	Regurgitant volume ≥30 mL Regurgitant fraction ≥50% ERO ≥0.20 cm ^2†	Regional wall motion abnormalities with reduced LV systolic function LV dilation and systolic dysfunction	HF symptoms due to MR persist after revascularization and medical therapy Decreased exercise tolerance Exertional dyspnea
*Several criteria are provided but not all criteria for each category will be present. Severity of mild, moderate, or serve is dependent on data quality and integration with other clinical evidence. ^†In secondary MR, true ERO is underestimated due to the crescentic shape of the proximal convergence
CAD = coronary heart disease; ERO = effective regurgitation orifice; HF = heart failure; IE = infective endocarditis; LA = left atrium; LV = left ventricular; LVEF = left ventricular ejection factor; LVESD = left ventricular end-systolic dimension; MR = mitral regurgitation; MV = mitral valve; TTE = transthoracic echocardiography.

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Author

Ivan Hanson, MD Assistant Professor of Medicine, Oakland University William Beaumont School of Medicine

Ivan Hanson, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography

Disclosure: Nothing to disclose.

Coauthor(s)

Luis C Afonso, MD Assistant Professor, Department of Internal Medicine-Cardiology, Program Director of Cardiology Fellowship Program, Wayne State University; Director of Echocardiography Laboratory, Harper University Hospital

Luis C Afonso, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Medical Association, American Society of Echocardiography

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ronald J Oudiz, MD, FACP, FACC, FCCP Professor of Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Liu Center for Pulmonary Hypertension, Division of Cardiology, LA Biomedical Research Institute at Harbor-UCLA Medical Center

Ronald J Oudiz, MD, FACP, FACC, FCCP is a member of the following medical societies: American College of Cardiology, American College of Chest Physicians, American College of Physicians, American Heart Association, American Thoracic Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Actelion, Bayer, Gilead, United Therapeutics<br/>Received research grant from: Actelion, Arena, Gilead, GSK, Liquidia, Reata, United Therapeutics<br/>Received income in an amount equal to or greater than $250 from: Actelion, Complexa, Gilead, Medtronic, Reata, United Therapeutics.

Chief Editor

Terrence X O'Brien, MD, MS, FACC Professor of Medicine/Cardiology, Director, Clinical Cardiovascular Research, Medical University of South Carolina College of Medicine; Director, Echocardiography Laboratory, Veterans Affairs Medical Center of Charleston

Terrence X O'Brien, MD, MS, FACC is a member of the following medical societies: American College of Cardiology, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, South Carolina Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors Shivkumar H Jha, MD; Jatin Dave, MD, MPH; Kishorkumar Desai, MD; and Abraham G Kocheril, MD, FACC, FACP to the development and writing of this article.

Mitral Regurgitation Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

References

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