Disproportionate mitral regurgitation: another myth? A critical appraisal of echocardiographic assessment of functional mitral regurgitation

Int J Cardiovasc Imaging. 2021 Jan;37(1):183-196. doi: 10.1007/s10554-020-01975-6. Epub 2020 Aug 26.


The contradictory findings of recent prospective randomized controlled trials assessing the impact of percutaneous edge-to-edge repair in patients with functional or secondary mitral regurgitation have triggered a lively discussion about an "integrated" echocardiographic approach for grading severity of mitral regurgitation. In the MITRA-FR trial, the COAPT trial and the REDUCE-FMR trial echocardiographic assessment of the severity of mitral regurgitation was consistent with principles set forth by the current echocardiographic guidelines and analysed in its best settings by expert international leaders in the field of echocardiography. However, serious inconsistencies appeared in the presented echocardiographic assessments regarding cardiac output and regurgitant fraction. A new term "disproportionate functional mitral regurgitation" was introduced describing a situation where the increase of effective regurgitant orifice area exceeds the enlargement of the left ventricular end-diastolic volumes. Further discussion resulted in the idea of a "new conceptional framework" for distinguishing "proportionate" and "disproportionate" functional mitral regurgitation. The aim of this viewpoint is to dispute conclusions based on the term "disproportionate" mitral regurgitation. A "disproportionate" FMR is highly questionable because disproportionateness of flow in communication vessels cannot exist. In addition, a proposal of echocardiographic assessment based on a conventional comprehensive transthoracic echocardiography is given to avoid obvious hemodynamic contradictions.

Keywords: Disproportionate mitral regurgitation; Echocardiography; Functional mitral regurgitation; Hemodynamics; Regurgitant fraction.

Publication types

  • Review

MeSH terms

  • Echocardiography*
  • Hemodynamics*
  • Humans
  • Mitral Valve / diagnostic imaging*
  • Mitral Valve / physiopathology
  • Mitral Valve Insufficiency / diagnostic imaging*
  • Mitral Valve Insufficiency / physiopathology
  • Predictive Value of Tests
  • Reproducibility of Results
  • Severity of Illness Index