---
title: Mitral regurgitation
description: What mitral regurgitation is, why it develops, how it is detected, which treatment approaches clinical guidelines describe and when urgent help is needed.
type: disease
aliases:
  - MR
  - mitral insufficiency
  - mitral valve regurgitation
sources:
  - tier: guideline
    org: esc
    title: 2025 ESC/EACTS Guidelines for the management of valvular heart disease
    year: 2025
    doi: 10.1093/eurheartj/ehaf194
    url: https://doi.org/10.1093/eurheartj/ehaf194
  - tier: guideline
    org: minzdrav-rf
    title: Митральная недостаточность
    year: 2024
    url: https://cr.minzdrav.gov.ru/view-cr/881_1
  - tier: guideline
    org: nice
    title: 'Heart valve disease presenting in adults: investigation and management (NG208)'
    year: 2021
    url: https://www.nice.org.uk/guidance/ng208
  - tier: reference
    org: statpearls
    title: Mitral Regurgitation
    year: 2024
    url: https://www.ncbi.nlm.nih.gov/books/NBK553135/
  - tier: reference
    org: msd-manuals
    title: Mitral Regurgitation
    year: 2025
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/mitral-regurgitation
  - tier: reference
    org: msd-manuals
    title: Cardiac Auscultation
    year: 2025
    url: https://www.msdmanuals.com/professional/cardiovascular-disorders/approach-to-the-cardiac-patient/cardiac-auscultation
sources_checked: 2026-10-12
review: null
---

Mitral regurgitation (mitral insufficiency) is a condition in which the leaflets of the <Structure id="mitral-valve">mitral valve</Structure> do not close fully while the ventricles contract (systole), so some blood flows back from the <Structure id="left-ventricle">left ventricle</Structure> into the <Structure id="left-atrium">left atrium</Structure>.<Cite n={[2, 4]} /> It is the second most common heart valve disease after aortic stenosis.<Cite n={2} />

<Diagram name="mitral-regurgitation">
  <p slot="normal">
    The diagram shows the moment the left ventricle contracts. Normally the mitral valve leaflets
    are closed at this time, so blood does not return to the left atrium but leaves the ventricle
    into the aorta.<Cite n={2} />
  </p>
  <p slot="disease">
    In mitral regurgitation the leaflets do not close while the ventricle contracts, and some blood
    flows back as a jet from the left ventricle into the left atrium.<Cite n={[2, 4]} /> In severe
    regurgitation the left atrium enlarges, which is why it is drawn larger here.<Cite n={2} />
  </p>
</Diagram>

## Why it happens

<Patient>

The causes fall into two groups. In primary regurgitation the valve itself is damaged: its leaflets, the thin cords (chordae) that hold the leaflets, or the papillary muscles the cords are attached to.<Cite n={4} /> The most common cause of chronic primary regurgitation is mitral valve prolapse.<Cite n={2} />

In secondary regurgitation the valve itself is normal, and the cause lies in the left ventricle: it contracts poorly or has changed shape and size.<Cite n={[2, 4]} />

Regurgitation can also develop suddenly (acute regurgitation), most often because a valve cord tears or a papillary muscle is damaged during a heart attack.<Cite n={2} />

</Patient>

<Student>

Primary mitral regurgitation (MR) results from structural deformity of or damage to the leaflets, chordae or papillary muscles; common causes are papillary muscle rupture, mitral valve prolapse (MVP) and leaflet perforation.<Cite n={4} /> MVP is the main cause of chronic primary MR and occurs in 2.4% of the population.<Cite n={2} />

Secondary MR results from severe systolic dysfunction and global or regional remodelling of the LV, with a structurally normal valve, for example in ischaemic cardiomyopathy.<Cite n={[2, 4]} /> The 2025 ESC guideline stresses that distinguishing atrial from ventricular secondary mitral regurgitation has implications for prognosis and management.<Cite n={1} /> Secondary MR is found in almost half of patients after myocardial infarction and may be severe in 3–13%; severe MR is found in one in four patients with dilated cardiomyopathy.<Cite n={2} />

Acute MR is most often caused by rupture of mitral valve chordae and by papillary muscle involvement in acute myocardial infarction (papillary muscle dysfunction or rupture); it causes an abrupt volume overload of the LV and LA.<Cite n={2} />

</Student>

<HeartModel highlight={['mitral-valve']} />

## Symptoms

<Patient>

Chronic regurgitation often causes no symptoms for a long time, sometimes until late in the disease.<Cite n={4} /> There are no complaints specific to it: the signs are mostly those of heart failure.<Cite n={2} /> Typically these are breathlessness, getting tired quickly and a pounding or racing heartbeat during physical activity.<Cite n={2} /> There may be breathlessness when lying flat and attacks of breathlessness at night.<Cite n={4} />

A heart rhythm problem, most often atrial fibrillation, can also be what brings a person to the doctor.<Cite n={2} />

Acute severe regurgitation looks different: sudden severe breathlessness at rest caused by fluid on the lungs (pulmonary oedema).<Cite n={[2, 4]} />

</Patient>

<Student>

MR has no specific symptoms; the clinical picture is mainly that of chronic heart failure.<Cite n={2} /> Patients with chronic MR often remain asymptomatic until late in the course of the disease; findings common to all aetiologies include fatigue, dyspnoea on exertion, orthopnoea and paroxysmal nocturnal dyspnoea.<Cite n={4} /> Patients may first present because of an arrhythmia, most often atrial fibrillation (AF).<Cite n={2} />

In acute severe MR (chordal rupture in MVP or papillary muscle rupture in acute myocardial infarction) the disease presents with pulmonary oedema.<Cite n={2} /> Typical features are significant dyspnoea at rest, worse in the supine position, and a precipitous decline in cardiac output, possibly with cardiogenic shock.<Cite n={4} />

</Student>

## How it is diagnosed

<Patient>

When listening to the heart, the doctor may hear a murmur that is loudest over the tip (apex) of the heart.<Cite n={4} /> If the doctor suspects valve disease because of the type of murmur, age, family history or past illnesses (for example, atrial fibrillation), guidelines advise considering an ultrasound scan of the heart even when there are no other signs.<Cite n={3} />

The key test is an ultrasound scan of the heart (echocardiogram). It shows why the valve lets blood leak back and how much.<Cite n={[2, 4]} /> If needed, a transoesophageal echocardiogram is done.<Cite n={2} />

</Patient>

<Student>

On auscultation there is a holosystolic murmur heard best at the apex.<Cite n={4} /> NICE suggests considering an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on the nature of the murmur, family history, age (especially over 75) or medical history (for example, AF).<Cite n={3} />

Echocardiography is the primary diagnostic test for diagnosing and assessing mitral regurgitation.<Cite n={4} /> Transthoracic echocardiography is recommended to identify the mechanism and severity of MR; transoesophageal echocardiography is recommended to assess mechanism and severity when clinically needed, but not for routine assessment of mitral valve morphology and haemodynamics when transthoracic findings are adequate.<Cite n={2} />

Criteria for severe primary MR in the Russian Ministry of Health guideline: central jet area more than 40% of the LA or a holosystolic eccentric jet, vena contracta ≥0.7 cm, regurgitant volume ≥60 mL, regurgitant fraction ≥50% and effective regurgitant orifice area (EROA) ≥0.40 cm².<Cite n={2} /> Haemodynamic consequences of severe MR are moderate or marked LA dilatation, LV enlargement, and pulmonary hypertension at rest or on exercise.<Cite n={2} />

</Student>

<HeartSounds sound="mitral-regurgitation" />

## How it is treated

<Patient>

In severe primary regurgitation that causes symptoms, the main treatment is an operation on the valve.<Cite n={[2, 3]} /> Whenever possible the valve is repaired rather than replaced; if it cannot be repaired, it is replaced with an artificial valve.<Cite n={[2, 3]} /> Sometimes surgery may be considered before symptoms appear, for example if a heart scan shows the left ventricle is working less well.<Cite n={3} />

If open surgery is not suitable, in some cases the valve is repaired through a blood vessel using a catheter (transcatheter edge-to-edge repair).<Cite n={[1, 3]} />

In severe secondary regurgitation, the Russian Ministry of Health guideline recommends treating heart failure with medicines for all patients.<Cite n={2} /> When surgery is not suitable, NICE also offers medical treatment.<Cite n={3} />

Which approach to take is discussed by a team of specialists: the treating cardiologist, heart imaging specialists, surgeons and interventional cardiologists.<Cite n={1} />

</Patient>

<Student>

Russian Ministry of Health guideline: surgery is recommended for patients with chronic severe MR and NYHA class II–IV symptoms; mitral valve repair on cardiopulmonary bypass is the preferred method.<Cite n={2} /> When a valve-sparing operation is not possible, mitral valve replacement with preservation of the subvalvular apparatus is the method of choice.<Cite n={2} /> NICE offers surgical mitral valve repair (by median sternotomy or minimally invasive surgery) for severe primary MR with an indication for repair, and replacement if the valve is not suitable for repair.<Cite n={3} />

In asymptomatic severe primary MR, NICE suggests considering referral for intervention if any of the following is present: LVEF less than 60%, LV end-systolic diameter more than 45 mm or ESD index more than 22 mm/m² on echocardiography, or an increase of systolic pulmonary artery pressure to more than 60 mm Hg on exercise testing.<Cite n={3} /> Referral decisions take into account the suitability of the valve for repair and the presence of AF or systolic pulmonary artery pressure of more than 50 mm Hg at rest.<Cite n={3} />

Transcatheter edge-to-edge repair (TEER; called transcatheter "end-to-end" mitral valve repair in the Russian guideline): according to the 2025 ESC guideline it should be considered in symptomatic patients with severe primary MR who are anatomically suitable and at high surgical risk according to the Heart Team.<Cite n={1} /> In ventricular secondary MR, TEER is recommended to reduce heart failure hospitalisations and improve quality of life in haemodynamically stable, symptomatic patients with LVEF below 50% and persistent severe MR despite optimised guideline-directed medical therapy and cardiac resynchronisation therapy (if indicated), who fulfil specific clinical and echocardiographic criteria.<Cite n={1} /> The Russian Ministry of Health guideline recommends heart failure drug therapy for all patients with severe secondary MR.<Cite n={2} /> In chronic severe secondary MR without coronary artery disease, the Russian Ministry of Health guideline recommends transcatheter edge-to-edge repair for symptomatic patients in whom surgical correction cannot be performed, if criteria suggest a high chance of a good response.<Cite n={2} /> For heart failure with severe secondary MR when surgery is unsuitable, NICE offers medical management and suggests considering TEER if symptoms persist on it.<Cite n={3} />

Decisions are made by the Heart Team; its core members include the treating cardiologist, imaging specialists, surgeons and interventional cardiologists with expertise in surgical and transcatheter valve procedures.<Cite n={1} />

</Student>

## When to call an ambulance

Acute severe mitral regurgitation presents with pulmonary oedema; cardiac output falls sharply and cardiogenic shock is possible.<Cite n={[2, 4]} /> It occurs when valve cords tear or papillary muscles are damaged during a heart attack.<Cite n={2} />

If sudden severe breathlessness at rest appears that gets worse when lying flat, or a cough with pink, frothy sputum, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK).<Cite n={4} />

<Quiz />