Dynamic Secondary Mitral Regurgitation: Current Evidence and Challenges for the Future

Figure 1. Dynamic changes in SMR during transesophageal echocardiography in a 66-year-old male patient who had an anterior old myocardial infarction and heart failure with reduced ejection fraction. Mild SMR (EROA 0.10 cm2) under sedation using midazolam under a systolic blood pressure of approximately 70 mm Hg. (A) Two-dimensional B-mode and color Doppler images from the intercommissural view and (B) a three-dimensional color Doppler image from the en-face view. Dynamic severe SMR (EROA 0.51 cm2) under an elevated systolic blood pressure of approximately 110 mm Hg using norepinephrine. (C) Two-dimensional B-mode and color Doppler images from the intercommissural view and (D) a three-dimensional color Doppler image from the en-face view. SMR, secondary mitral regurgitation; EROA, effective regurgitant orifice area.

Figure 2. Dynamic changes in SMR during exercise stress echocardiography in an 85-year-old male patient who had an anterior old myocardial infarction and heart failure with reduced ejection fraction. Moderate SMR (EROA 0.22 cm2) at rest. (A,B) Two-dimensional color Doppler images from three- and two-chamber views. Dynamic severe SMR (EROA 0.46 cm2) under stress. (C,D) Two-dimensional color Doppler images from three-chamber and two-chamber views. SMR, secondary mitral regurgitation; EROA, effective regurgitant orifice area.

Figure 3. Dynamic changes of SMR during exercise stress echocardiography before CRT and controlled SMR following CRT during exercise stress echocardiography in a 71-year-old male patient who had an anterior old myocardial infarction and heart failure with reduced ejection fraction. (A) Complete left bundle branch block with a QRS duration of 154 ms in the electrocardiogram before CRT. (B,C) Mild SMR (EROA 0.14 cm2) at rest and dynamic moderate-to-severe SMR (EROA 0.32 cm2) under stress in two-dimensional color Doppler images from the three-chamber view before CRT. (D) Non-left bundle branch block with a QRS duration of 128 ms in the electrocardiogram after CRT. (E,F) Trivial SMR at rest and under stress 1 year after the CRT in two-dimensional color Doppler images from the three-chamber view after CRT. SMR, secondary mitral regurgitation; CRT, cardiac resynchronization therapy, EROA, effective regurgitant orifice area.

Figure 4. Dynamic changes in SMR during exercise stress echocardiography before TEER and controlled SMR following TEER during exercise stress echocardiography in an 83-year-old male patient who had an anterior and inferior old myocardial infarction and heart failure with reduced ejection fraction after CRT. (A,B) Trivial SMR at rest in two-dimensional color Doppler images from four-chamber and two-chamber views. (C,D) Dynamic severe SMR (EROA 0.52 cm2) under stress in two-dimensional color Doppler images from four-chamber and two-chamber views. (E,F) Mild MR under stress 6 months after the TEER in two-dimensional color Doppler images from four-chamber and two-chamber views. SMR, secondary mitral regurgitation; TEER, transcatheter edge-to-edge repair; CRT, cardiac resynchronization therapy; EROA, effective regurgitant orifice area; MR, mitral regurgitation.