Signs
Specific signs of severity
Mild:
  • Small central jet <4 cm2 or <20% of LA area(3)
  • Vena contracta width <0.3 cm
  • No or minimal flow convergence(5)
Moderate:
  • Signs of MR>mild present but no criteria for severe MR
Severe:
  • Vena contracta width ≥0.7 cm with large central MR jet (area >40% of LA) or with a wall-impinging jet of any size, swirling in LA(3)
  • Large flow convergence(5)
  • Systolic reversal in pulmonary veins
  • Prominent flail MV leaflet or ruptured papillary muscle
Supportive signs
Mild:
  • Systolic dominant flow in pulmonary veins
  • A-wave dominant mitral inflow(3)
  • Soft density, parabolic CW Doppler MR signal
  • Normal LV size(1)
Moderate:
  • Intermediate signs/findings
Severe:
  • Dense, triangular CW Doppler MR jet
  • E-wave dominant mitral inflow (E >1.2 m/s)(4) Enlarged LV and LA size(2), (particularly when normal LV function is present).
Quantitative parameters(5)
R Vol (mL/beat)
Mild:<30
Mild-Moderate:30-44
Moderate-Severe:45-59
Severe:≥60
RF (%)
Mild:<30
Mild-Moderate:30-39
Moderate-Severe:40-49
Severe:≥50
EROA (cm2)
Mild:<0.20
Mild-Moderate:0.20-0.29
Moderate-Severe:0.30-0.39
Severe:≥0.40

CW, Continuous wave; EROA, effective regurgitant orifice area; LA, left atrium; LV, left ventricle; MV, mitral valve; MR, mitral regurgitation; R Vol, regurgitant volume; RF, regurgitant fraction.

Based on data in the literature and a consensus of the committee members, the Task Force proposes a scheme of specific signs (≥90% specificity), along with supportive signs and quantitative parameters to help grade the severity of MR (Table 1). In applying this scheme, the Task Force also wishes to recognize the following. The specific signs have inherently a high positive predictive value for the severity of regurgitation. On the other hand, the supportive signs or clues may be helpful in consolidating the impression of the degree of MR, although their predictive value is more modest, since they are influenced by several factors (Table 3). The process of grading MR should be comprehensive, using a combination of clues, signs and measurements obtained by Doppler-echocardiography.

  1. LV size applied only to chronic lesions. Normal 2D measurements: LV minor axis ≤2.8 cm/m2, LV end-diastolic volume ≤82 mL/m2, maximal LA antero-posterior diameter ≤2.8 cm/m2, maximal LA volume ≤36 mL/m2 (2;33;35).
  2. In the absence of other etiologies of LV and LA dilatation and acute MR.
  3. At a Nyquist limit of 50-60 cm/s.
  4. Usually above 50 years of age or in conditions of impaired relaxation, in the absence of mitral stenosis or other causes of elevated LA pressure.
  5. Minimal and large flow convergence defined as a flow convergence radius <0.4 cm and ≤0.9 cm for central jets, respectively, with a baseline shift at a Nyquist of 40 cm/s; Cut-offs for eccentric jets are higher, and should be angle corrected.
  6. Quantitative parameters can help sub-classify the moderate regurgitation group into mild-to-moderate and moderate-to-severe as shown.