COR LOE Recommendation In patients with primary MR (Stages B to D) and new-onset or changing symptoms, TTE is indicated to evaluate the mitral valve apparatus and LV function.1,2 Synopsis A repeat TTE provides clinically relevant information about patients who are being followed for primary MR who develop new-onset symptoms. Table 17. Stages of Chronic Primary MR Stage Definition Valve Anatomy Valve Hemodynamics* Hemodynamic Consequences Symptoms A At risk of MR Mild mitral valve prolapse with normal coaptation Mild valve thickening and leaflet restriction No MR jet or small central jet area <20% LA on Doppler Small vena contracta <0.3 cm None None B Progressive MR Moderate to severe mitral valve prolapse with normal coaptation Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Central jet MR 20% 40% LA or late systolic eccentric jet MR Vena contracta <0.7 cm Regurgitant volume <60 mL Regurgitant fraction <50% Angiographic grade 1+ to 2+ Mild LA enlargement No LV enlargement Normal pulmonary pressure None C Asymptomatic severe MR Severe mitral valve prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta 0.7 cm Regurgitant volume 60 mL Regurgitant fraction 50% Angiographic grade 3+ to 4+ Moderate or severe LA enlargement LV enlargement Pulmonary hypertension may be present at rest or with exercise LVESD <40 mm LVESD 40 mm None D Symptomatic severe MR Severe mitral valve prolapse with loss of coaptation or flail leaflet Rheumatic valve changes with leaflet restriction and loss of central coaptation Prior IE Thickening of leaflets with radiation heart disease Central jet MR >40% LA or holosystolic eccentric jet MR Vena contracta 0.7 cm Regurgitant volume 60 mL Regurgitant fraction 50% Angiographic grade 3+ to 4+ Moderate or severe LA enlargement LV enlargement Pulmonary hypertension present Decreased exercise tolerance Exertional dyspnea *Several valve hemodynamic criteria are provided for assessment of MR severity, but not all criteria for each category will be present in each patient. 