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CC. MR is likely severe.

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*A Comprehensive (Level I) Valve Center should have the resources and capabilities to evaluate and perform all commercially approved interventional and surgical procedures. A Level I center should also have advanced imaging modalities (e.g., 3D echocardiography, cardiac magnetic resonance) that may not be available at a Level II center.

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Decision Tree for Assessing Severity of Chronic MR by TTE

Additional Considerations:

When uncertainty exists regarding MR severity based on clinical and echocardiographic assessment (i.e., mild to moderate or moderate to severe), consider further testing.
Further testing may include right and left heart catheterization, stress echo, TEE, or CMR in select circumstances.
Color Doppler can often overestimate MR. This is most common with high blood pressure, high LV systolic pressure in AS or HOCM, peak velocities ≥6.0 m/s, or single frame measurements (PISA, VCW, VCA) in non-holosystolic MR.
Color Doppler can also underestimate MR severity. This is most common with high LA pressures, low LV ejection fraction or large LA/LV volumes.
Adjunctive criteria that support mild MR include a soft or incomplete MR jet on CW Doppler, normal PA systolic pressure or MR duration <30% of systole.
Adjunctive criteria that support severe MR include a dense triangular CW Doppler profile, a well-aligned CW MR jet velocity <4.5 m/s indicating high LAP, dilated LA or LV with no other cause, and PA systolic pressure >50 mmHg with no other cause, systolic PV flow reversal and significant mitral inflow E wave dominance with high velocity (>1.2-1.5 m/s) in the absence of mitral stenosis.

Abbreviations: AS = aortic stenosis; CMR = cardiovascular magnetic resonance; CW = color wave; EROA = effective regurgitant orifice area; HOCM = hypertrophic obstructive cardiomyopathy; LA = left atrium; LAP = left atrial pressure; LV = left ventricle; MR = mitral regurgitation; PA = Pulmonary artery; PISA = proximal isovelocity surface area; RF = regurgitant fraction; RVol = regurgitant volume; TTE = transthoracic echocardiogram; VCA = vena contracta width; VCW = vena contracta area

Strengths and Limitations of Common ECHO Parameters

Parameter	Strengths	Weaknesses
Valve Morphology	Flail leaflets or ruptured papillary muscles are specific for severe MR	Other findings are non-specific
Regurgitant Color Flow	Easy to use, evaluates spatial orientation of MR jet, differentiates mild versus severe	Subject to technical and hemodynamic variation; can be underestimated with wallimpinging jets; image quality dependent
Vena Contracta Width	Quick and easy to use; independent of hemodynamic and instrumentation factors; applies to eccentric jets; can differentiate mild versus severe MR	Not applicable to multiple jets; intermediate values require confirmation; small measurement errors can lead to big changes; 2D measure of a 3D structure; limited lateral resolution
Proximal Isovelocity Surface Area (PISA)	Can be applied to eccentric jets (when angle corrected); not affected by etiology of MR; quantitative: provides both lesion severity (EROA) and volume data (R Vol)	Not valid with multiple jets; provides peak flow and maximal EROA; inter-observer variability; errors in radius measurement are squared; multiple potential sources of measurement error
Flow Quantitation–PW	Quantitative; valid in multiple jets and eccentric jets; provides both lesion severity (EROA, RF) and volume data (RVol)	Time consuming; measurement of flow at MV annulus less reliable with calcified MV and/or annulus; not valid with concomitant significant AR unless pulmonic site is used;requires measurement at multiple sites, which introduces errors
Jet Profile–CW	Simple, readily available Easy assessment of MR timing	Qualitative; complementary data; complete signal difficult to obtain in eccentric jet; gain dependent
Peak Mitral E Velocity	Simple, readily available, A-wave dominance excludes severe MR	Influenced by LA pressure/compliance, LV relaxation, MV area, and AF; complementary data only, does not quantify MR severity
Pulmonary Vein Flow	Simple; systolic flow reversal is specific for severe MR	Influenced by LA pressure, AF; not accurate if MR jet directed into the sampled vein; absence does not rule out severe MR
LA and LV Size	Enlargement sensitive for chronic severe MR, important for outcomes; normal size virtually excludes severe chronic MR	Enlargement seen in other conditions (non-specific); may be normal in acute severe MR

Abbreviations: AF = atrial fibrillation; AR = aortic regurgitation; CW = continuous wave; EROA = effective
regurgitant orifice area; LA = left atrium; LV = left ventricle; MR = mitral regurgitation; MV = mitral valve; RF =regurgitant fraction; RVol = regurgitant volume

Pathoanatomically Directed Surgical Techniques for MR

Primary Mitral Regurgitation
1.	Non-resection techniques using either polytetrafluorethylene (PTFE) neochord reconstruction or ipsilateral chordal transfer from secondary to primary position, with annuloplasty ring May be used for focal leaflet flail or bileaflet prolapse May be used for forme fruste* diffuse myxomatous disease of the posterior leaflet May be used for isolated anterior leaflet prolapse
2.	Focal triangular resection with annuloplasty ring May be used for focal leaflet flail of the posterior or commissural leaflet Rarely may be used for focal anterior leaflet defects
3.	Sliding leaflet valvuloplasty with annuloplasty ring May be used for forme fruste* diffuse posterior leaflet myxomatous disease May be used in the setting of bileaflet prolapse with excess posterior leaflet May be used in any of the above with significant echocardiographic predictors of systolic anterior motion of the anterior mitral valve leaflet
Secondary Mitral Regurgitation
1.	Restrictive remodeling rigid annuloplasty ring May be used as primary modality for annular dilatation mechanism May be used in conjunction with secondary or tertiary chordal cutting May be used with other adjunctive procedures (i.e., papillary muscle sling) Should be avoided as sole therapy in setting of Carpentier Type IIIB mechanism with left ventricular inferobasal aneurysm
2.	Chord-sparing mitral valve replacement May be used as primary modality for annular dilatation with severe leaflet tethering (i.e., > 10 mm tenting height) or presence of inferobasal aneurysm Reasonable to consider in preference to mitral valve repair for patients with severe ischemic mitral regurgitation

* See text. Forme fruste refers to a pathoanatomic form of primary MR intermediate between fibroelastic deficiency and Barlow’s disease.

Feasibility of Surgical Mitral Valve Repair

	Ideal Pathoanatomy	Challenging Pathoanatomy	Relative Pathoanatomic Contraindications
Primary Lesion Location	Posterior Leaflet only	Anterior Leaflet or Bi-leaflet	None
Leaflet calcification	None	Mild	Moderate to severe
Annular calcification	None	Mild to moderate with minimal leaflet encroachment	Severe or with significant leaflet encroachment
Subvalvular Apparatus	Thin, normal	Mild diffuse thickening or moderate focal thickening	Severe and diffuse thickening with leaflet retraction
Mechanism of MR	Type II fibroelastic deficiency or focal myxomatous prolapse or flail	Type II forme fruste or bileaflet myxomatous (Barlow’s) disease; Type I healed or active endocarditis; Type III A/B with mild restriction or leaflet thickening	Type IIIB with severe tethering and inferobasal aneurysm; Type IIIA with severe bileaflet calcification, Type I active infection with severe leaflet or annular tissue destruction
Unique Anatomic Complexities	None	Redo cardiac operation or mitral re-repair; anatomic predictors of systolic anterior motion (i.e. septal hypertrophy); adult congenital anomalies; focal papillary muscle rupture	Mitral valve reoperation with paucity of leaflet tissue; diffuse radiation valvulopathy; papillary muscle rupture with shock

Eligibility for Transcatheter Mitral Valve Intervention

Feasibility of Transcatheter Edge-to-Edge Clip Repair

	Favorable Features^*	Less or Unfavorable Features^*
Location of Leaflet Pathology	Noncommissural pathology (Medial, middle, lateral segments).	Commissural segments, leaflet perforations or clefts
Calcification	None or minimal calcification	Severe leaflet calcification or calcification in area of grasping zone Severe annular calcification
Mean MV gradient	Transmitral gradient < 4 mm	Mitral stenosis (rheumatic or calcific; mean mitral gradient > 5 mmHg)
Mitral valve area	MVA ≥ 4.0 cm²	MVA < 4.0 cm²
Grasping Zone length	> 10 mm	< 7 mm
Primary MR	Flail width < 15 mm; flail gap < 10 mm; single segment pathology Normal leaflet thickness	Flail width > 15 mm and flail gap > 10 mm Multi-segment pathology; highly mobile flail leaflet with multiple ruptured chords Severely and diffusely thickened (5 mm in diastole) and redundant leaflets (Barlow's type valve); LVESD > 55 mm
Secondary MR	Coaptation depth < 11 mm; coaptation length (overlap length) ≥ 2mm	LVESD > 70 mm

^*Knowledge continues to evolve regarding case selection; highly experienced operators at comprehensive valve centers may achieve good procedural results in selected cases with unfavorable anatomic features.
Abbreviations: LVESD = LV end-diastolic dimension, MR = mitral regurgitation, MV, mitral valve, MVA = MV area

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References

Bonow RO, O’Gara PT, Adams DH, Badhwar V, Bavaria JE, Elmariah S, Hung JW, Lindenfeld J, Morris AA, Satpathy R, Whisenant B, Woo YJ
2020 Focused Update of the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation
Journal of the American College of Cardiology (2020), doi: https:// doi.org/10.1016/j.jacc.2020.02.005

Carpentier Atrial View Image: Castillo JG, Solís J, González-Pinto Á, Adams DH.
Surgical Echocardiography of the Mitral Valve.
Revista Española de Cardiología (English Edition) 2011;64:1169-1181.

O’Gara PT, Grayburn PA, Badhwar V, Afonso LC, Carroll JD, Elmariah S, Kithcart AP, Nishimura RA, Ryan T, Schwartz A, Stevenson LW.
2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation: A Report of the American College of Cardiology Task Force on Expert Consensus Decision Pathway.
J Am Coll Cardiol. 2017 Nov, 70 (19) 2421–2449.

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, Jneid H, Mack MJ, McLeod CJ, O’Gara PT, Rigolin VH, Sundt TM, Thompson A.
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 Practice Guidelines.
J AM Coll Cardiol 2017: DOI: 10.1016/j.jacc.2017.03.011

Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM, Thomas JD.
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;57-185

Nishimura RA, O’Gara PT, Bavaria JE, Brindis RG, Carroll JD, Kavinsky CJ, Lindman BR, Linderbaum JA, Little SH, Mack MJ, Mauri L, Miranda WR, Shahian DM, Sundt TM 3rd.
2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.
J Am Coll Cardiol 2019;73:2609–35

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About the App

When was this App last updated?

January 2024

How can I provide feedback?

Click here to fill out our feedback survey

How is the ManageMR app intended to be used?

ManageMR provides clinicians with personalized referral and treatment advice for patients diagnosed with mitral regurgitation by verifying the severity and etiology of the MR. For optimal use:

Conduct a clinical assessment of your patient with suspected chronic mitral regurgitation, including assessment of qualitative and quantitative parameters, symptoms, exercise tolerance, physical exam and chamber sizes.
- Use the MR Echo Reporting Checklist tool to help review and report echo parameters in a standardized way. A link to this tool can be found in the orange introductory box of the app, or here

Using the results of the initial assessment, input the required patient parameters into the Evaluate screen of the app.

Review app’s advice on the Advice screen regarding:
- - suspected level and probability of MR severity
- - indicated mechanism and etiology of MR
- - whether additional testing is suggested
Consider the advice in conjunction with initial clinical assessment.

If patient’s MR is severe, review suggestions on the Advice screen regarding intervention next steps for your patient, and use it to help inform treatment decisions.

Based on the definition of your patient’s MR, use the app’s Advice screen to help determine if monitoring or referral to additional experts is suggested for your patient. If need for referral is determined by the clinician, they can use the MR Referral Checklist tool to help facilitate a comprehensive referral handoff.

Use the Email button on the app’s Advice tab to email yourself a summary of the advice given by the app.

Visit the Resources tab in the app for
- - additional reference material regarding the management of MR
- - more clinician tools to help implement guidance from the ACC/AHA Valvular Heart Disease Guideline and ACC’s Mitral Regurgitation Expert Consensus Clinical Pathway
- - patient tools to help patient’s monitor and manage their own MR

The information and recommendations in this App are meant to support clinical decision making. They are not meant to represent the only or best course of care, or replace clinical judgment. Therapeutic options should be determined after discussion between the patient and their care provider.

How was the ManageMR app developed?

The content for this App is derived from the 2020 ACC Focused Update to the 2017 ACC Expert Consensus Decision Pathway on the Management of Mitral Regurgitation. App content and design was further refined and vetted by ACC member clinicians, and through user testing with clinicians practicing in relevant specialties.

This app was developed as part of a continuing initiative to enable clinicians to access and implement ACC clinical policy at the point of care for better patient care and outcomes. Previous versions of the app were developed as part of the ACC's Emerging Mitral Regurgitation Clinical Care (EMC2) Initiative, and was supported by Founding Sponsor Abbott Vascular. All content was independently developed with no sponsor involvement.

Where can I go if I have questions?

For Support
Call: (202) 375-6000, ext. 5603 or (800) 253-4636
Email: MemberCare@acc.org

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Evaluate * Answer each question in the series below to view Advice.

What is the SEVERITY of Patient's MR?

Which of the Following did Diagnostic Testing Indicate?

Select All Criteria Typical of Severe MR That Apply to Your Patient:

What is the ETIOLOGY of the Patient's MR?

Large Crescentic Orifice?

Select All Criteria Typical of Mild MR That Apply to Your Patient:

Hidden Severity

Hidden Etiology

Select Quantitative Grade That Best Describes Your Patient:

Grade I

Grade II

Grade III

Grade IV

Unknown

Is Flail Leaflet or Tethering Present?

Candidate for surgery?

Select Leaflet Morphology

LVEF < 50%?

Is revascularization indicated?

Is CABG preferred or is there a need for other surgery?

After initiating or intensifying GDMT, does the patient have ongoing HF symtpoms?

Candidate for CRT?

Likelihood of successful repair > 95% AND Peri-op risk < 1%?

Select the Carpentier Classification of Leaflet Motion

Normal - Type I

Prolapse or Flail - Type II

Restricted in Both Systole & Diastole - Type IIIA

Restricted in Systole Only - Type IIIB

Select Symptom Status

Are Any of the Following Additional Characteristics Present?• Ejection Fraction < 0.6• Left Ventricular End-Systolic Diameter > 4.0 cm• Serial Increase in LV Size or Decrease in LV Function Over Time• Recent-onset Atrial Fibrillation• Pulmonary Artery Systolic Pressure > 50 mmHg

Advice

Severity

CC. MR is likely severe.

Inputs

Resources

Decision Tree for Assessing Severity of Chronic MR by TTE

Strengths and Limitations of Common ECHO Parameters

Pathoanatomically Directed Surgical Techniques for MR

Feasibility of Surgical Mitral Valve Repair

Eligibility for Transcatheter Mitral Valve Intervention

Feasibility of Transcatheter Edge-to-Edge Clip Repair

Clinician Tools

Patient Tools and Resources

Other Mobile Tools

References

Terms of Service

ManageMR Terms of Service and License Agreement

Term and Termination

Intellectual Property Rights

Limitation of Liability

Release of Liability

Indemnification

Disclaimer of Warranties

Force Majeure

No Assignment

No Waiver

Severability

Governing Law

Certification

About the App

When was this App last updated?

How can I provide feedback?

How is the ManageMR app intended to be used?

How was the ManageMR app developed?

Where can I go if I have questions?

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Evaluate
* Answer each question in the series below to view Advice.

Are Any of the Following Additional Characteristics Present?
• Ejection Fraction < 0.6
• Left Ventricular End-Systolic Diameter > 4.0 cm
• Serial Increase in LV Size or Decrease in LV Function Over Time
• Recent-onset Atrial Fibrillation
• Pulmonary Artery Systolic Pressure > 50 mmHg