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

Natural history of chronic mitral regurgitation caused by mitral valve prolapse and flail mitral leaflet

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


An understanding of the natural history of chronic mitral regurgitation (MR) is an essential part of any medical or surgical management plan. The natural history is variable, depending upon the etiology and the stage at which the disease is first diagnosed.

The major causes of MR are primary diseases of the valve apparatus and secondary (functional) MR due to cardiomyopathy or coronary disease. The causes of primary MR include mitral valve prolapse (MVP), rheumatic heart disease, infective endocarditis, and trauma, which can lead to a flail (or partial flail) mitral leaflet. (See "Clinical manifestations and diagnosis of chronic mitral regurgitation", section on 'Etiology' and "Management and prognosis of chronic secondary mitral regurgitation".)

The best natural history data that are presently available have come from studies of patients with MVP and flail mitral leaflet, which is usually a consequence of degenerative mitral valve disease (eg, MVP). These findings may not apply to MR of other causes, especially ischemic and functional MR.

This topic will review the natural history of chronic primary MR caused by MVP and of flail mitral leaflet. The indications for surgery in chronic MR are discussed separately. (See "Indications for intervention for severe chronic primary mitral regurgitation".)


Overview — The estimated prevalence of mitral valve prolapse (MVP) using modern echocardiographic techniques is 0.6 to 2.4 percent [1,2]. The natural history of MVP is generally benign, but serious complications do occur; the most common are infective endocarditis, cerebrovascular accidents, the need for mitral valve surgery, and death. (See "Nonarrhythmic complications of mitral valve prolapse" and "Arrhythmic complications of mitral valve prolapse".)

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: Nov 2017. | This topic last updated: Nov 19, 2015.
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. Flack JM, Kvasnicka JH, Gardin JM, et al. Anthropometric and physiologic correlates of mitral valve prolapse in a biethnic cohort of young adults: the CARDIA study. Am Heart J 1999; 138:486.
  2. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341:1.
  3. Allen H, Harris A, Leatham A. Significance and prognosis of an isolated late systolic murmur: a 9- to 22-yearyearfollow-up. Br Heart J 1974; 36:525.
  4. Mills P, Rose J, Hollingsworth J, et al. Long-term prognosis of mitral-valve prolapse. N Engl J Med 1977; 297:13.
  5. Nishimura RA, McGoon MD, Shub C, et al. Echocardiographically documented mitral-valve prolapse. Long-term follow-up of 237 patients. N Engl J Med 1985; 313:1305.
  6. Düren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic mitral valve prolapse in 300 patients: a prospective study. J Am Coll Cardiol 1988; 11:42.
  7. Vered Z, Oren S, Rabinowitz B, et al. Mitral valve prolapse. Quantitative analysis and long-term follow-up. Isr J Med Sci 1985; 21:644.
  8. Marks AR, Choong CY, Sanfilippo AJ, et al. Identification of high-risk and low-risk subgroups of patients with mitral-valve prolapse. N Engl J Med 1989; 320:1031.
  9. Avierinos JF, Detaint D, Messika-Zeitoun D, et al. Risk, determinants, and outcome implications of progression of mitral regurgitation after diagnosis of mitral valve prolapse in a single community. Am J Cardiol 2008; 101:662.
  10. Avierinos JF, Gersh BJ, Melton LJ 3rd, et al. Natural history of asymptomatic mitral valve prolapse in the community. Circulation 2002; 106:1355.
  11. Zuppiroli A, Rinaldi M, Kramer-Fox R, et al. Natural history of mitral valve prolapse. Am J Cardiol 1995; 75:1028.
  12. Kim S, Kuroda T, Nishinaga M, et al. Relationship between severity of mitral regurgitation and prognosis of mitral valve prolapse: echocardiographic follow-up study. Am Heart J 1996; 132:348.
  13. Ling LH, Enriquez-Sarano M, Seward JB, et al. Clinical outcome of mitral regurgitation due to flail leaflet. N Engl J Med 1996; 335:1417.
  14. Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation 1999; 99:400.
  15. Gillinov AM, Cosgrove DM, Blackstone EH, et al. Durability of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998; 116:734.
  16. Avierinos JF, Inamo J, Grigioni F, et al. Sex differences in morphology and outcomes of mitral valve prolapse. Ann Intern Med 2008; 149:787.
  17. Grigioni F, Avierinos JF, Ling LH, et al. Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome. J Am Coll Cardiol 2002; 40:84.
  18. Berbarie RF, Roberts WC. Frequency of atrial fibrillation in patients having mitral valve repair or replacement for pure mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol 2006; 97:1039.
  19. Freed LA, Benjamin EJ, Levy D, et al. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. J Am Coll Cardiol 2002; 40:1298.
  20. Enriquez-Sarano M, Basmadjian AJ, Rossi A, et al. Progression of mitral regurgitation: a prospective Doppler echocardiographic study. J Am Coll Cardiol 1999; 34:1137.
  21. St John Sutton M, Weyman AE. Mitral valve prolapse prevalence and complications: an ongoing dialogue. Circulation 2002; 106:1305.
  22. Topilsky Y, Michelena H, Bichara V, et al. Mitral valve prolapse with mid-late systolic mitral regurgitation: pitfalls of evaluation and clinical outcome compared with holosystolic regurgitation. Circulation 2012; 125:1643.
  23. Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol 1996; 28:1083.
  24. Gaasch WH, Aurigemma GP. Inhibition of the renin-angiotensin system and the left ventricular adaptation to mitral regurgitation. J Am Coll Cardiol 2002; 39:1380.
  25. Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005; 352:875.
  26. Otto CM, Salerno CT. Timing of surgery in asymptomatic mitral regurgitation. N Engl J Med 2005; 352:928.
  27. Gaasch WH, Meyer TE. Left ventricular response to mitral regurgitation: implications for management. Circulation 2008; 118:2298.
  28. Rosenhek R, Rader F, Klaar U, et al. Outcome of watchful waiting in asymptomatic severe mitral regurgitation. Circulation 2006; 113:2238.
  29. Ling LH, Enriquez-Sarano M, Seward JB, et al. Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. Circulation 1997; 96:1819.
  30. Grigioni F, Tribouilloy C, Avierinos JF, et al. Outcomes in mitral regurgitation due to flail leaflets a multicenter European study. JACC Cardiovasc Imaging 2008; 1:133.