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Proportionate or disproportionate secondary mitral regurgitation: how to untangle the Gordian knot?
  1. Victor Kamoen,
  2. Simon Calle,
  3. Marc De Buyzere,
  4. Frank Timmermans
  1. Cardiology, University Hospital Ghent, Ghent, Belgium
  1. Correspondence to Professor Frank Timmermans, Department of Cardiology, University Hospital Ghent, Ghent 9000, Belgium; frank.timmermans{at}


Recent randomised percutaneous mitral intervention trials in patients with heart failure with secondary mitral regurgitation (SMR) have yielded contrasting results. A ‘relative load’ or ‘proportionality’ conceptual framework for SMR has been proposed to partly explain the disparate results. The rationale behind the framework is that SMR depends on the left ventricular dimension and not vice versa. In this review, we provide an in-depth analysis of the proportionality parameters used in this framework and also discuss the regurgitant fraction. We also consider haemodynamic observations in SMR that may affect the interpretation and comparisons among proportionality parameters. The conclusion is that the proportionality concept remains hypothetical and requires prospective validation before envisaging its use at individual patient level for risk stratification or therapeutic decision-making.

  • mitral regurgitation
  • echocardiography
  • cardiac imaging and diagnostics

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  • Contributors VK: manuscript writing. SC: manuscript writing. MDB: manuscript writing. FT: manuscript writing. FT is responsible for the overall content as guarantor. Each of the authors has contributed equally to the review paper.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.