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Functional vs Primary MR — EECC MCQ

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EasyHeart FailureFunctional vs Primary MREECC

A 60-year-old man with HFrEF (LVEF 25%) and moderate-severe functional MR is assessed. His cardiologist explains that functional MR is fundamentally different from primary MR. What is the key distinction?

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Correct answer: E — In functional (secondary) MR, the mitral valve leaflets are structurally normal — the regurgitation is caused by LV dilatation, papillary muscle displacement, and annular dilatation distorting the subvalvular apparatus; treatment targets the underlying LV disease first

Primary (organic/degenerative) MR results from intrinsic valve pathology (myxomatous degeneration, flail leaflet, chordal rupture, endocarditis, rheumatic). Functional (secondary) MR results from LV and/or LA remodelling with structurally normal leaflets — mechanisms include: (1) ischaemic MR (papillary muscle displacement from LV remodelling post-MI); (2) non-ischaemic MR (global LV dilatation in DCM); (3) atrial functional MR (LA dilatation and annular dilatation in long-standing AF). Treatment differs fundamentally: primary MR → valve repair/replacement when severe; functional MR → optimise LV-directed therapy (GDMT) first, then consider TEER (COAPT criteria) or surgical intervention if MR remains severe despite optimal medical therapy.

Reference: ESC/EACTS (2025): VHD Guidelines; ESC (2023): HF Guidelines