Mitral valve training › Guides › Ischaemic MR (posterior tethering)

Ischaemic (secondary) mitral regurgitation on echo

What to look for: Inferior wall akinesia, a restricted posterior leaflet, a posterior jet.

Key findings

• Secondary (ischaemic) MR: the leaflets are normal, but an infarcted, remodelled LV tethers them (type IIIb).
• After an inferior or inferolateral infarct the posteromedial papillary muscle is displaced and tethers the posterior leaflet: the jet is directed posteriorly.
• The coaptation point is pulled below the annular plane, towards the apex (tenting); note the tenting height and area.
• The regurgitation varies with loading and ischaemia; exercise echo can show it rising with exercise.
• Look at the inferior and inferolateral walls: the disease is in the LV, not in the valve.

Grading the regurgitation (secondary MR)

• Severe: EROA ≥0.40 cm² or regurgitant volume ≥60 ml; with low flow, EROA ≥0.30 cm² or regurgitant volume ≥45 ml may already be severe.
• The orifice is often crescent-shaped along the coaptation line, so a single PISA can underestimate it.
• Severity changes with loading, rhythm and treatment: grade it on optimal heart failure treatment and note the conditions.

Pitfalls

• A posterior jet hugging the LA wall looks smaller than it is by colour area (the Coanda effect): rely on the vena contracta, the flow convergence and the other signs.

In the simulator every case varies the anatomy, the jets and the measurements: watch the lesion in Learn, then grade new cases in Practice and compare your answer with the exact one.

Related

Functional MR in a dilated LV (symmetric tethering) · Atrial functional MR

Educational simulation to use under the supervision of a clinical tutor — not for clinical use.