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

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Disproportionate mitral regurgitation: another myth? A critical appraisal of echocardiographic assessment of functional mitral regurgitation Andreas Hagendorff1,11   · Fabian Knebel2,3 · Andreas Helfen4,5 · Stephan Stöbe1 · Torsten Doenst6 · Volkmar Falk7,8,9,10 Received: 1 June 2020 / Accepted: 17 August 2020 © The Author(s) 2020

Abstract The contradictory findings of recent prospective randomized controlled trials assessing the impact of percutaneous edgeto-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  Functional mitral regurgitation · Disproportionate mitral regurgitation · Hemodynamics · Regurgitant fraction · Echocardiography Hagendorff Disproportionate FMR—Another Myth? * Andreas Hagendorff [email protected]‑leipzig.de 1

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Department of Cardiothoracic and Vascular Surgery, University of Berlin, Charité‑Universitätsmedizin Berlin, Berlin, Germany



Department of Cardiology, University of Leipzig, Leipzig, Germany

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Department of Cardiology, University of Berlin, Charité‑Universitätsmedizin Berlin, Berlin, Germany

Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany

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Speaker of the Working Group „Cardiovascular Ultrasound“ of the German Society of Cardiology, Düsseldorf, Germany

Department of Health Science and Technology, Swiss Federal Institute of Technology, Zurich, Switzerland

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Department of Cardiology, St. Marien Hospital Lünen, Lünen, Germany

German Center of Cardiovascular Research, Partner Site Berlin, Berlin, Germany

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Co-Speaker of the Working Group „Cardiovascular Ultrasound“ of the