Figure 9. Impact of restrictive mitral valve annuloplasty (RMA) on exercise hemodynamics and transmitral gradients in secondary mitral valve regurgitation (MR).

The mitral valve area after RMA increases during exercise because of an increasing anterior leaflet opening angle. This suggests that the functional stenosis after RMA relates to impaired diastolic anterior leaflet opening (i.e., ongoing tethering). Impaired effective orifice area at peak exercise is associated with worse outcomes. Adapted from Bertrand et al¹⁰³ with permission.