The correct answer is: B. Functional (secondary) MR

CHOICE A – incorrect - The anterior leaflet never rises above the annulus.

CHOICE C – incorrect - The leaflets open normally in diastole.

CHOICE D – incorrect - The posterior wall motion abnormality and low LVEF excludes this diagnosis.

CHOICE E – incorrect - The anterior leaflet does not prolapse.

CHOICE B – correct - This is classic functional MR with posterior wall motion abnormality and severe tethering of the posterior leaflet toward the apex. The anterior leaflet is in its normal position but overrides the tethered posterior leaflet. It is not prolapse because in the long-axis view it never moves 2 mm above the annulus.

This is anterior leaflet override, not prolapse.

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Anterior Leaflet Override

MR Quantitation

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MR Quantitation

Optimal treatment of secondary MR

• Max tolerated doses of GDMT (forced titration protocols)
• CRT when indicated
• Coronary revascularization when indicated
• Surgical mitral valve repair/replacement currently lack data demonstrating improved survival
• COAPT trial showed improved HF hospitalization (primary), mortality and multiple other pre-specified endpoints

Educational grant support provided by Abbott Structural Heart

References

1. Levine RA, Schwammethal E. Ischemic Mitral Regurgitation on the Threshold of a Solution: From Paradoxes to Unifying Concepts. Circulation 2005;112(5):745-58.
2. Levine RA, Handschumacher MD, Sanfilippo AJ, et al. Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation 1989;80(3):589-98.