Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Management and prognosis of chronic secondary mitral regurgitation

William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Management of patients with chronic secondary mitral regurgitation (MR) requires an understanding of the pathophysiology and natural history of the disease and the efficacy and timing of treatment, particularly mitral valve repair and replacement. While our knowledge of these areas is incomplete, a rational plan for management based upon the available evidence is presented here [1,2].

Secondary MR (also known as functional MR) is caused by left ventricular dysfunction caused by coronary heart disease or by a cardiomyopathy. Secondary MR caused by coronary heart disease (generally with myocardial infarction) is known as ischemic MR. In contrast, primary MR is caused by primary abnormality of one or more components of the valve apparatus. Identification of the cause and type (primary or secondary) of MR is required for appropriate management of MR and associated conditions.

The pathophysiology, diagnosis, and evaluation of chronic MR, the management of chronic primary MR, and the management of acute MR are presented elsewhere. (See "Pathophysiology of chronic mitral regurgitation" and "Clinical manifestations and diagnosis of chronic mitral regurgitation" and "Management of chronic primary mitral regurgitation" and "Acute mitral regurgitation in adults" and "Acute mitral regurgitation in adults", section on 'Treatment'.)


Staging of secondary mitral regurgitation (MR) is based upon symptoms, valve anatomy, and valve hemodynamics (severity of MR), which are associated with left ventricular (LV) dysfunction (due to coronary artery disease or cardiomyopathy) as described in the 2014 American Heart Association/American College of Cardiology valvular heart disease guidelines (table 1) [1]:

In stage A, patients are at risk of MR (or have mild MR). Mitral valve leaflets, chords, and annulus are normal with no or mild MR (small central jet <20 percent of left atrium on color Doppler with vena contracta <0.3 cm). Patients with coronary artery disease have normal or mildly dilated LV size with fixed (myocardial infarction) or inducible (ischemia) regional wall motion abnormalities. Patients with cardiomyopathy have abnormal LV geometry, usually with dilation and systolic dysfunction.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Oct 2017. | This topic last updated: Apr 21, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. 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.
  2. Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
  3. Reed D, Abbott RD, Smucker ML, Kaul S. Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size. Circulation 1991; 84:23.
  4. Shiran A, Merdler A, Ismir E, et al. Intraoperative transesophageal echocardiography using a quantitative dynamic loading test for the evaluation of ischemic mitral regurgitation. J Am Soc Echocardiogr 2007; 20:690.
  5. Leung DY, Griffin BP, Stewart WJ, et al. Left ventricular function after valve repair for chronic mitral regurgitation: predictive value of preoperative assessment of contractile reserve by exercise echocardiography. J Am Coll Cardiol 1996; 28:1198.
  6. Magne J, Lancellotti P, Piérard LA. Exercise-induced changes in degenerative mitral regurgitation. J Am Coll Cardiol 2010; 56:300.
  7. Magne J, Lancellotti P, Piérard LA. Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation. Circulation 2010; 122:33.
  8. Donal E, Mascle S, Brunet A, et al. Prediction of left ventricular ejection fraction 6 months after surgical correction of organic mitral regurgitation: the value of exercise echocardiography and deformation imaging. Eur Heart J Cardiovasc Imaging 2012; 13:922.
  9. Dini FL, Fontanive P, Conti U, et al. Plasma N-terminal protype-B natriuretic peptide levels in risk assessment of patients with mitral regurgitation secondary to ischemic and nonischemic dilated cardiomyopathy. Am Heart J 2008; 155:1121.
  10. Trichon BH, O'Connor CM. Secondary mitral and tricuspid regurgitation accompanying left ventricular systolic dysfunction: is it important, and how is it treated? Am Heart J 2002; 144:373.
  11. Seneviratne B, Moore GA, West PD. Effect of captopril on functional mitral regurgitation in dilated heart failure: a randomised double blind placebo controlled trial. Br Heart J 1994; 72:63.
  12. Keren G, Pardes A, Eschar Y, et al. One-year clinical and echocardiographic follow-up of patients with congestive cardiomyopathy treated with captopril compared to placebo. Isr J Med Sci 1994; 30:90.
  13. Capomolla S, Febo O, Gnemmi M, et al. Beta-blockade therapy in chronic heart failure: diastolic function and mitral regurgitation improvement by carvedilol. Am Heart J 2000; 139:596.
  14. Lowes BD, Gill EA, Abraham WT, et al. Effects of carvedilol on left ventricular mass, chamber geometry, and mitral regurgitation in chronic heart failure. Am J Cardiol 1999; 83:1201.
  15. Groenning BA, Nilsson JC, Sondergaard L, et al. Antiremodeling effects on the left ventricle during beta-blockade with metoprolol in the treatment of chronic heart failure. J Am Coll Cardiol 2000; 36:2072.
  16. Cirit M, Ozkahya M, Cinar CS, et al. Disappearance of mitral and tricuspid regurgitation in haemodialysis patients after ultrafiltration. Nephrol Dial Transplant 1998; 13:389.
  17. Breithardt OA, Sinha AM, Schwammenthal E, et al. Acute effects of cardiac resynchronization therapy on functional mitral regurgitation in advanced systolic heart failure. J Am Coll Cardiol 2003; 41:765.
  18. Cleland JG, Daubert JC, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med 2005; 352:1539.
  19. Abraham WT, Fisher WG, Smith AL, et al. Cardiac resynchronization in chronic heart failure. N Engl J Med 2002; 346:1845.
  20. van Bommel RJ, Marsan NA, Delgado V, et al. Cardiac resynchronization therapy as a therapeutic option in patients with moderate-severe functional mitral regurgitation and high operative risk. Circulation 2011; 124:912.
  21. Brandt RR, Reiner C, Arnold R, et al. Contractile response and mitral regurgitation after temporary interruption of long-term cardiac resynchronization therapy. Eur Heart J 2006; 27:187.
  22. Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
  23. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
  24. Diodato MD, Moon MR, Pasque MK, et al. Repair of ischemic mitral regurgitation does not increase mortality or improve long-term survival in patients undergoing coronary artery revascularization: a propensity analysis. Ann Thorac Surg 2004; 78:794.
  25. Wong DR, Agnihotri AK, Hung JW, et al. Long-term survival after surgical revascularization for moderate ischemic mitral regurgitation. Ann Thorac Surg 2005; 80:570.
  26. Mihaljevic T, Lam BK, Rajeswaran J, et al. Impact of mitral valve annuloplasty combined with revascularization in patients with functional ischemic mitral regurgitation. J Am Coll Cardiol 2007; 49:2191.
  27. Smith PK, Puskas JD, Ascheim DD, et al. Surgical treatment of moderate ischemic mitral regurgitation. N Engl J Med 2014; 371:2178.
  28. Michler RE, Smith PK, Parides MK, et al. Two-Year Outcomes of Surgical Treatment of Moderate Ischemic Mitral Regurgitation. N Engl J Med 2016; 374:1932.
  29. Kang DH, Sun BJ, Kim DH, et al. Percutaneous versus surgical revascularization in patients with ischemic mitral regurgitation. Circulation 2011; 124:S156.
  30. Fattouch K, Guccione F, Sampognaro R, et al. POINT: Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial. J Thorac Cardiovasc Surg 2009; 138:278.
  31. Chan KM, Punjabi PP, Flather M, et al. Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial. Circulation 2012; 126:2502.
  32. Deja MA, Grayburn PA, Sun B, et al. Influence of mitral regurgitation repair on survival in the surgical treatment for ischemic heart failure trial. Circulation 2012; 125:2639.
  33. Bach DS, Bolling SF. Early improvement in congestive heart failure after correction of secondary mitral regurgitation in end-stage cardiomyopathy. Am Heart J 1995; 129:1165.
  34. Bolling SF, Pagani FD, Deeb GM, Bach DS. Intermediate-term outcome of mitral reconstruction in cardiomyopathy. J Thorac Cardiovasc Surg 1998; 115:381.
  35. Chen FY, Adams DH, Aranki SF, et al. Mitral valve repair in cardiomyopathy. Circulation 1998; 98:II124.
  36. Wu AH, Aaronson KD, Bolling SF, et al. Impact of mitral valve annuloplasty on mortality risk in patients with mitral regurgitation and left ventricular systolic dysfunction. J Am Coll Cardiol 2005; 45:381.
  37. Mehra MR, Griffith BP. Is mitral regurgitation a viable treatment target in heart failure? The plot just thickened. J Am Coll Cardiol 2005; 45:388.
  38. Acker MA, Parides MK, Perrault LP, et al. Mitral-valve repair versus replacement for severe ischemic mitral regurgitation. N Engl J Med 2014; 370:23.
  39. Goldstein D, Moskowitz AJ, Gelijns AC, et al. Two-Year Outcomes of Surgical Treatment of Severe Ischemic Mitral Regurgitation. N Engl J Med 2016; 374:344.
  40. Vassileva CM, Boley T, Markwell S, Hazelrigg S. Meta-analysis of short-term and long-term survival following repair versus replacement for ischemic mitral regurgitation. Eur J Cardiothorac Surg 2011; 39:295.
  41. Rao C, Murphy MO, Saso S, et al. Mitral valve repair or replacement for ischaemic mitral regurgitation: a systematic review. Heart Lung Circ 2011; 20:555.
  42. Levine RA, Schwammenthal E. Ischemic mitral regurgitation on the threshold of a solution: from paradoxes to unifying concepts. Circulation 2005; 112:745.
  43. McGee EC, Gillinov AM, Blackstone EH, et al. Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2004; 128:916.
  44. Hung J, Papakostas L, Tahta SA, et al. Mechanism of recurrent ischemic mitral regurgitation after annuloplasty: continued LV remodeling as a moving target. Circulation 2004; 110:II85.
  45. Kongsaerepong V, Shiota M, Gillinov AM, et al. Echocardiographic predictors of successful versus unsuccessful mitral valve repair in ischemic mitral regurgitation. Am J Cardiol 2006; 98:504.
  46. Di Mauro M, Calafiore AM, Penco M, et al. Mitral valve repair for dilated cardiomyopathy: predictive role of right ventricular dysfunction. Eur Heart J 2007; 28:2510.
  47. Leor J, Feinberg MS, Vered Z, et al. Effect of thrombolytic therapy on the evolution of significant mitral regurgitation in patients with a first inferior myocardial infarction. J Am Coll Cardiol 1993; 21:1661.
  48. Chua S, Hung J, Chung SY, et al. Primary percutaneous coronary intervention lowers the incidence of ischemic mitral regurgitation in patients with acute ST-elevated myocardial infarction. Circ J 2010; 74:2386.
  49. Poh KK, Lee GK, Lee LC, et al. Reperfusion therapies reduce ischemic mitral regurgitation following inferoposterior ST-segment elevation myocardial infarction. Coron Artery Dis 2012; 23:555.
  50. Aklog L, Filsoufi F, Flores KQ, et al. Does coronary artery bypass grafting alone correct moderate ischemic mitral regurgitation? Circulation 2001; 104:I68.
  51. Penicka M, Linkova H, Lang O, et al. Predictors of improvement of unrepaired moderate ischemic mitral regurgitation in patients undergoing elective isolated coronary artery bypass graft surgery. Circulation 2009; 120:1474.
  52. Hausmann H, Siniawski H, Hetzer R. Mitral valve reconstruction and replacement for ischemic mitral insufficiency: seven years' follow up. J Heart Valve Dis 1999; 8:536.
  53. Borger MA, Murphy PM, Alam A, et al. Initial results of the chordal-cutting operation for ischemic mitral regurgitation. J Thorac Cardiovasc Surg 2007; 133:1483.
  54. de Varennes B, Chaturvedi R, Sidhu S, et al. Initial results of posterior leaflet extension for severe type IIIb ischemic mitral regurgitation. Circulation 2009; 119:2837.
  55. Blondheim DS, Jacobs LE, Kotler MN, et al. Dilated cardiomyopathy with mitral regurgitation: decreased survival despite a low frequency of left ventricular thrombus. Am Heart J 1991; 122:763.
  56. Koelling TM, Aaronson KD, Cody RJ, et al. Prognostic significance of mitral regurgitation and tricuspid regurgitation in patients with left ventricular systolic dysfunction. Am Heart J 2002; 144:524.
  57. Conti JB, Mills RM Jr. Mitral regurgitation and death while awaiting cardiac transplantation. Am J Cardiol 1993; 71:617.
  58. Dini FL, Conti U, Fontanive P, et al. Right ventricular dysfunction is a major predictor of outcome in patients with moderate to severe mitral regurgitation and left ventricular dysfunction. Am Heart J 2007; 154:172.
  59. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001; 122:1125.
  60. Tcheng JE, Jackman JD Jr, Nelson CL, et al. Outcome of patients sustaining acute ischemic mitral regurgitation during myocardial infarction. Ann Intern Med 1992; 117:18.
  61. Lehmann KG, Francis CK, Dodge HT. Mitral regurgitation in early myocardial infarction. Incidence, clinical detection, and prognostic implications. TIMI Study Group. Ann Intern Med 1992; 117:10.
  62. Barzilai B, Davis VG, Stone PH, Jaffe AS. Prognostic significance of mitral regurgitation in acute myocardial infarction. The MILIS Study Group. Am J Cardiol 1990; 65:1169.
  63. Pellizzon GG, Grines CL, Cox DA, et al. Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial. J Am Coll Cardiol 2004; 43:1368.
  64. Bursi F, Enriquez-Sarano M, Nkomo VT, et al. Heart failure and death after myocardial infarction in the community: the emerging role of mitral regurgitation. Circulation 2005; 111:295.
  65. Perez de Isla L, Zamorano J, Quezada M, et al. Prognostic significance of functional mitral regurgitation after a first non-ST-segment elevation acute coronary syndrome. Eur Heart J 2006; 27:2655.
  66. Aronson D, Goldsher N, Zukermann R, et al. Ischemic mitral regurgitation and risk of heart failure after myocardial infarction. Arch Intern Med 2006; 166:2362.
  67. Grigioni F, Enriquez-Sarano M, Zehr KJ, et al. Ischemic mitral regurgitation: long-term outcome and prognostic implications with quantitative Doppler assessment. Circulation 2001; 103:1759.
  68. Lamas GA, Mitchell GF, Flaker GC, et al. Clinical significance of mitral regurgitation after acute myocardial infarction. Survival and Ventricular Enlargement Investigators. Circulation 1997; 96:827.
  69. Tischler MD, Cooper KA, Rowen M, LeWinter MM. Mitral valve replacement versus mitral valve repair. A Doppler and quantitative stress echocardiographic study. Circulation 1994; 89:132.
  70. Feinberg MS, Schwammenthal E, Shlizerman L, et al. Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction. Am J Cardiol 2000; 86:903.
  71. Grossi EA, Goldberg JD, LaPietra A, et al. Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications. J Thorac Cardiovasc Surg 2001; 122:1107.
  72. Grigioni F, Detaint D, Avierinos JF, et al. Contribution of ischemic mitral regurgitation to congestive heart failure after myocardial infarction. J Am Coll Cardiol 2005; 45:260.