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Smer et al. Mini-invasive Surg 2020;4:52 I http://dx.doi.org/10.20517/2574-1225.2020.36 Page 13 of 15

the assumption of hemispherical proximal flow conversion zone is even further disrupted by the device [1,14] .
The use of 3D echocardiography could help overcome some of these limitations.

SPECTRAL DOPPLER
Spectral Doppler remains useful and provides important parameters for quantitative assessment of MR
severity [Table 3]. Both the mitral to aortic TVI ratio of > 1.4 and the systolic flow reversal into pulmonary
veins are specific signs of severe MR. Similar to the quantitative volumetric method, the pulsed wave
[36]
Doppler method is time-consuming and has several limitations .

ROLE OF STRESS TESTING
Both in primary and secondary MR, exercise stress echocardiography can provide additional diagnostic
[37]
and prognostic information in asymptomatic patients . For patients with severe MR and equivocal
symptoms, exercise testing can be useful in assessing symptomatic status and functional capacity.
[38]
Inadequate increase in LV ejection fraction with exercise predicts worse postoperative LV function . In
2
secondary MR, an increase in EROA > 0.13 cm during exercise is associated with worse cardiovascular
[37]
outcomes . Currently, there is no role for pharmacological stress echocardiography in evaluation of MR
severity.
CONCLUSION
2D echo imaging is the modality of choice for evaluating the etiology and mechanism of MR and associated
lesions. MR severity in real world practice is semi-quantitatively assessed by eyeballing the proportion of
the LA area occupied by the regurgitant jet on 2D/color Doppler imaging. This is supplemented by linear
measurements of flow convergence and VC. When MR appears moderately severe or severe by these
methods and intervention, where MitraClip is a consideration, more comprehensive and complicated
quantitative echo methods, which may include 3D imaging, are used.

DECLARATIONS
Authors’ contributions
Read and approved the manuscript: Smer A, Nanda NC, Akdogan RE, Elmarzouky ZM, Dulal S

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2020.