Mitral Regurgitation

Primary MR

Secondary MR

Persistent NYHA class III-IV symptoms

Periodic monitoring

MV surgery^*  (IIb)

End

Periodic monitoring

Symptomatic (stage D)

Asymptomatic (stage C)

MV surgery^*  (I)

MV surgery^*  (IIb)

LVEF >30%

Yes

No

MV repair (IIa)

CAD, coronary artery disease; CRT, cardiac resynchronization therapy; ERO, effective regurgitant orifice; HF, heart failure; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; MR, mitral regurgitation, MV, mitral valve; MVR, mitral valve replacement; NYHA, New York Heart Association; PASP, pulmonary artery systolic pressure; RF, regurgitant fraction; RVol, regurgitant volume; and Rx, therapy.

^*  MV repair is preferred over MV replacement when possible.

Class I

Class IIa

Class IIb

CAD Rx
HF Rx
Consider CRT

Symptomatic severe MR (stage D)

Asymptomatic severe MR (stage C)

Progressive MR (stage B)

Severe MR
Vena contracta 0.7 cm
RVol 60 mL
RF 50%
ERO 0.4 cm² 
LV dilation

Progressive MR (stage B)
Vena contracta <0.7 cm
RVol <60 mL
RF <50%
ERO <0.4 cm² 

LVEF 30 to 60%
LVESD 40 mm (stage C2)

LVEF >60% and LVESD <40 mm (stage C1)

New onset AF or PASP >50 mmHg (stage C1)

Likehood of successful repair >95% and expected mortality <1%

Yes

No

MV surgery (IIa)

Progressive increase in LVESD or decrease in EF

Likehood of successful repair >95% and expected mortality <1%