{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T16:00:51Z","timestamp":1777046451130,"version":"3.51.4"},"reference-count":73,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T00:00:00Z","timestamp":1776988800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Italian Ministry of Health, Ricerca Corrente IRCCS MultiMedica"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Risk stratification of patients with mitral regurgitation (MR), including both primary (degenerative) and secondary (functional) forms, remains challenging, particularly in asymptomatic or minimally symptomatic stages, as clinical assessment and resting echocardiography may underestimate disease severity and functional impairment. Exercise stress echocardiography (ESE) enables dynamic evaluation of regurgitation severity, ventricular performance, and cardiopulmonary response, potentially improving prognostic assessment. Methods: A systematic review was conducted according to PRISMA guidelines. PubMed, Scopus, and EMBASE were searched from inception to March 2026. Studies including adult patients with primary or secondary MR undergoing exercise-based stress echocardiography and reporting clinical outcomes were selected. Studies using exclusively pharmacological stress were excluded. Data were qualitatively synthesized, and continuous variables were summarized as weighted medians and interquartile ranges. In addition, emerging and non-conventional prognostic markers, including anatomical indices such as the modified Haller index (MHI), were explored to provide a more comprehensive risk stratification framework. Results: Nineteen studies were included, encompassing a heterogeneous population in terms of MR etiology, severity, and clinical presentation. During follow-up, a substantial proportion of patients experienced adverse events, including heart failure, mitral valve intervention, or death. Exercise-derived parameters consistently showed strong prognostic value. In particular, exercise-induced worsening of MR severity (increase in effective regurgitant orifice area and regurgitant volume), absence of contractile reserve, elevated filling pressures (E\/e\u2019), and exercise-induced pulmonary hypertension were associated with worse outcomes. Reduced functional capacity and impaired right ventricular\u2013pulmonary arterial coupling provided additional prognostic information. Emerging markers, including chest wall configuration assessed by MHI, appeared to further refine risk stratification in selected patient subsets. In contrast, resting parameters were less consistently predictive. Conclusions: ESE provides incremental prognostic information in patients with MR by identifying dynamic abnormalities not evident at rest. Its integration into clinical evaluation, together with novel anatomical and functional markers, may improve risk stratification and support earlier identification of high-risk patients who could benefit from timely intervention. Further studies are needed to standardize methodologies and define clinically relevant thresholds.<\/jats:p>","DOI":"10.3390\/jcm15093253","type":"journal-article","created":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T14:28:23Z","timestamp":1777040903000},"page":"3253","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Unmasking Risk in Mitral Regurgitation: Prognostic Value of Exercise Stress Echocardiography\u2014A Systematic Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7641-8831","authenticated-orcid":false,"given":"Andrea","family":"Sonaglioni","sequence":"first","affiliation":[{"name":"Division of Cardiology, IRCCS MultiMedica, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Massimo","family":"Baravelli","sequence":"additional","affiliation":[{"name":"Division of Cardiology, IRCCS MultiMedica, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-7084-9442","authenticated-orcid":false,"given":"Giulio Francesco","family":"Gramaglia","sequence":"additional","affiliation":[{"name":"Department of Emergency, Fondazione IRCSS Ca\u2019 Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2218-2808","authenticated-orcid":false,"given":"Gian Luigi","family":"Nicolosi","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Policlinico San Giorgio, 33170 Pordenone, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michele","family":"Lombardo","sequence":"additional","affiliation":[{"name":"Division of Cardiology, IRCCS MultiMedica, 20123 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,4,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Figlioli, G., Sticchi, A., Christodoulou, M.N., Hadjidemetriou, A., Amorim Moreira Alves, G., De Carlo, M., Praz, F., Caterina, R., Nikolopoulos, G.K., and Bonovas, S. (2025). Global Prevalence of Mitral Regurgitation: A Systematic Review and Meta-Analysis of Population-Based Studies. J. Clin. Med., 14.","DOI":"10.3390\/jcm14082749"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"109","DOI":"10.4103\/aca.aca_221_24","article-title":"The Mechanisms and Pathophysiology of Mitral Regurgitation: A Narrative Review","volume":"28","author":"Neema","year":"2025","journal-title":"Ann. Card. Anaesth."},{"key":"ref_3","first-page":"e61191","article-title":"Navigating Asymptomatic Mitral Regurgitation: Diagnostic Dilemmas and Treatment Strategies","volume":"16","author":"Saeed","year":"2024","journal-title":"Cureus"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1038\/s41572-023-00478-7","article-title":"Degenerative mitral regurgitation","volume":"9","author":"Delgado","year":"2023","journal-title":"Nat. Rev. Dis. Primers"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1247","DOI":"10.1007\/s10741-021-10100-1","article-title":"Speckle tracking echocardiography in primary mitral regurgitation: Should we reconsider the time for intervention?","volume":"27","author":"Pastore","year":"2022","journal-title":"Heart Fail. Rev."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"927","DOI":"10.1161\/CIRCULATIONAHA.124.073674","article-title":"Clinical Presentation and Outcomes After Surgery for Mitral Regurgitation: Real-World Insights From the MITRACURE International Registry","volume":"152","author":"Chu","year":"2025","journal-title":"Circulation"},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Marchetti, D., Di Lenarda, F., Novembre, M.L., Paolisso, P., Schillaci, M., Melotti, E., Doldi, M., Terzi, R., Gallazzi, M., and Conte, E. (2023). Contemporary Echocardiographic Evaluation of Mitral Regurgitation and Guidance for Percutaneous Mitral Valve Repair. J. Clin. Med., 12.","DOI":"10.3390\/jcm12227121"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Rolando, M., Elmasry, N., Gobbi, F., Moreo, A., Ajmone Marsan, N., Carluccio, E., and Fortuni, F. (2025). Echocardiographic Assessment of Patients Undergoing Mitral Valve Repair. J. Cardiovasc. Dev. Dis., 12.","DOI":"10.3390\/jcdd12120498"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"e70052","DOI":"10.1111\/echo.70052","article-title":"Mitral Regurgitation Evaluation in Modern Echocardiography: Bridging Standard Techniques and Advanced Tools for Enhanced Assessment","volume":"42","author":"Leo","year":"2025","journal-title":"Echocardiography"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1186\/s13613-023-01163-4","article-title":"Mitral regurgitation in the critically ill: The devil is in the detail","volume":"13","author":"Duncan","year":"2023","journal-title":"Ann. Intensive Care"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"47079","DOI":"10.31083\/RCM47079","article-title":"Exercise Stress Echocardiography: A Dynamic Assessment for an Evolving Landscape","volume":"27","author":"Vilela","year":"2026","journal-title":"Rev. Cardiovasc. Med."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Correra, A., Mauriello, A., Del Giudice, C., Fonderico, C., Di Peppo, M., Russo, V., D\u2019Andrea, A., Esposito, G., and Brunetti, N.D. (2026). The Incremental Role of Stress Echocardiography in Valvular Heart Disease: A Narrative Review. Diagnostics, 16.","DOI":"10.3390\/diagnostics16010148"},{"key":"ref_13","first-page":"465","article-title":"Prognostic value of left ventricular global longitudinal strain in mitral regurgitation: A systematic review","volume":"28","author":"Ueyama","year":"2023","journal-title":"Heart Fail. Rev."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1594","DOI":"10.1161\/CIRCULATIONAHA.125.073778","article-title":"Prognostic Value of Exercise Right Ventricular-Pulmonary Arterial Coupling in Primary Mitral Regurgitation","volume":"152","author":"Pugliese","year":"2025","journal-title":"Circulation"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1007\/s11886-022-01765-7","article-title":"The Role of Stress Echocardiography in Valvular Heart Disease","volume":"24","author":"Citro","year":"2022","journal-title":"Curr. Cardiol. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Altes, A., Vermes, E., Levy, F., Vancraeynest, D., Pasquet, A., Vincentelli, A., Gerber, B.L., Tribouilloy, C., and Mar\u00e9chaux, S. (2023). Quantification of primary mitral regurgitation by echocardiography: A practical appraisal. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1107724"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"e003478","DOI":"10.1136\/openhrt-2025-003478","article-title":"Prognostic impact of mitral regurgitation in elderly patients with atrial fibrillation: Results from the CABANA trial","volume":"12","author":"Wu","year":"2025","journal-title":"Open Heart"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Gallo, G., Forte, M., Stanzione, R., Cotugno, M., Bianchi, F., Marchitti, S., Berni, A., Volpe, M., and Rubattu, S. (2020). Functional Role of Natriuretic Peptides in Risk Assessment and Prognosis of Patients with Mitral Regurgitation. J. Clin. Med., 9.","DOI":"10.3390\/jcm9051348"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_20","first-page":"7","article-title":"Methodological quality (risk of bias) assessment tools for primary and secondary medical studies: What are they and which is better?","volume":"7","author":"Ma","year":"2020","journal-title":"Mil. Med. Res."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1713","DOI":"10.1161\/01.CIR.0000087599.49332.05","article-title":"Prognostic importance of exercise-induced changes in mitral regurgitation in patients with chronic ischemic left ventricular dysfunction","volume":"108","author":"Lancellotti","year":"2003","journal-title":"Circulation"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1407","DOI":"10.1136\/hrt.2004.047613","article-title":"Functional and prognostic implications of left ventricular contractile reserve in patients with asymptomatic severe mitral regurgitation","volume":"91","author":"Lee","year":"2005","journal-title":"Heart"},{"key":"ref_23","first-page":"18","article-title":"Prognostic value of mitral regurgitation assessment during exercise echocardiography in patients with left ventricular dysfunction: A follow-up study of 1.7 +\/\u2212 1.5 years","volume":"9","author":"Peteiro","year":"2008","journal-title":"Eur. J. Echocardiogr."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1293","DOI":"10.1093\/eurjhf\/hfs114","article-title":"Prognostic importance of exercise brain natriuretic peptide in asymptomatic degenerative mitral regurgitation","volume":"14","author":"Magne","year":"2012","journal-title":"Eur. J. Heart Fail."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1608","DOI":"10.1093\/eurheartj\/eht345","article-title":"Left ventricular contractile reserve in asymptomatic primary mitral regurgitation","volume":"35","author":"Magne","year":"2014","journal-title":"Eur. Heart J."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1310","DOI":"10.1161\/CIRCULATIONAHA.113.005287","article-title":"Predictors of long-term outcomes in patients with significant myxomatous mitral regurgitation undergoing exercise echocardiography","volume":"129","author":"Naji","year":"2014","journal-title":"Circulation"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"e001010","DOI":"10.1161\/JAHA.114.001010","article-title":"Importance of exercise capacity in predicting outcomes and determining optimal timing of surgery in significant primary mitral regurgitation","volume":"3","author":"Naji","year":"2014","journal-title":"J. Am. Heart Assoc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e001348","DOI":"10.1161\/JAHA.114.001348","article-title":"Impact of duration of mitral regurgitation on outcomes in asymptomatic patients with myxomatous mitral valve undergoing exercise stress echocardiography","volume":"4","author":"Naji","year":"2015","journal-title":"J. Am. Heart Assoc."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1136\/heartjnl-2014-306296","article-title":"Impact of exercise pulmonary hypertension on postoperative outcome in primary mitral regurgitation","volume":"101","author":"Magne","year":"2015","journal-title":"Heart"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1016\/j.amjcard.2015.02.028","article-title":"Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation","volume":"115","author":"Lancellotti","year":"2015","journal-title":"Am. J. Cardiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1974","DOI":"10.1016\/j.jacc.2016.08.030","article-title":"Strain Echocardiography and Functional Capacity in Asymptomatic Primary Mitral Regurgitation with Preserved Ejection Fraction","volume":"68","author":"Mentias","year":"2016","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_32","first-page":"296","article-title":"Mitral regurgitation in heart failure: Insights from CPET combined with exercise echocardiography","volume":"18","author":"Bandera","year":"2017","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"387","DOI":"10.1016\/j.ijcard.2017.02.063","article-title":"Additive prognostic values of NT-proBNP and exercise stress echocardiography in asymptomatic patients with degenerative mitral regurgitation and preserved left ventricular ejection fraction","volume":"236","author":"Park","year":"2017","journal-title":"Int. J. Cardiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"855","DOI":"10.1136\/heartjnl-2017-312097","article-title":"Right ventricular exercise contractile reserve and outcomes after early surgery for primary mitral regurgitation","volume":"104","author":"Vitel","year":"2018","journal-title":"Heart"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1007\/s12574-018-0404-6","article-title":"Prognostic value of exercise stress echocardiography in patients with secondary mitral regurgitation: A long-term follow-up study","volume":"17","author":"Suzuki","year":"2019","journal-title":"J. Echocardiogr."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1093\/ehjci\/jeaa200","article-title":"Prognostic impact of transcatheter mitral valve repair in patients with exercise-induced secondary mitral regurgitation","volume":"22","author":"Izumo","year":"2021","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"29","DOI":"10.4103\/jcecho.jcecho_71_21","article-title":"Impact of Chest Wall Conformation on the Outcome of Primary Mitral Regurgitation due to Mitral Valve Prolapse","volume":"32","author":"Sonaglioni","year":"2022","journal-title":"J. Cardiovasc. Echogr."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"108","DOI":"10.1093\/ehjci\/jeac039","article-title":"Additive prognostic and diagnostic value of diastolic exercise parameters in patients referred for exercise echocardiography","volume":"24","author":"Peteiro","year":"2022","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"e037198","DOI":"10.1161\/JAHA.124.037198","article-title":"Exercise Right Ventricular-Pulmonary Arterial Coupling and Functional Outcome in Patients Undergoing Surgery for Secondary Ischemic Mitral Regurgitation","volume":"14","author":"Fino","year":"2025","journal-title":"J. Am. Heart Assoc."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1016\/j.jcmg.2018.12.031","article-title":"Left Atrial Dynamics During Exercise in Mitral Regurgitation of Primary and Secondary Origin: Pathophysiological Insights by Exercise Echocardiography Combined with Gas Exchange Analysis","volume":"13","author":"Sugimoto","year":"2020","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1016\/j.jacc.2009.12.073","article-title":"Exercise-induced changes in degenerative mitral regurgitation","volume":"56","author":"Magne","year":"2010","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"2298","DOI":"10.1161\/CIRCULATIONAHA.107.755942","article-title":"Left ventricular response to mitral regurgitation: Implications for management","volume":"118","author":"Gaasch","year":"2008","journal-title":"Circulation"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"51","DOI":"10.5830\/CVJA-2017-009","article-title":"Left ventricular remodelling in chronic primary mitral regurgitation: Implications for medical therapy","volume":"29","author":"McCutcheon","year":"2018","journal-title":"Cardiovasc. J. Afr."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"492","DOI":"10.1097\/HCO.0b013e3283565c3b","article-title":"Stress testing for the evaluation of patients with mitral regurgitation","volume":"27","author":"Lancellotti","year":"2012","journal-title":"Curr. Opin. Cardiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"1317","DOI":"10.1161\/CIRCULATIONAHA.117.033173","article-title":"Clinical Outcome of Degenerative Mitral Regurgitation: Critical Importance of Echocardiographic Quantitative Assessment in Routine Practice","volume":"138","author":"Antoine","year":"2018","journal-title":"Circulation"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"732","DOI":"10.1007\/s00392-021-01807-0","article-title":"Impact of effective regurgitant orifice area on outcome of secondary mitral regurgitation transcatheter repair","volume":"110","author":"Karam","year":"2021","journal-title":"Clin. Res. Cardiol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1883","DOI":"10.1002\/ehf2.15195","article-title":"Exercise-induced dynamic mitral regurgitation is associated with outcomes in patients with ischaemic cardiomyopathy","volume":"12","author":"Spieker","year":"2025","journal-title":"ESC Heart Fail."},{"key":"ref_48","first-page":"177","article-title":"Contractile reserve induced with dobutamine echocardiography predicts outcome in patients with left ventricular dysfunction and mitral regurgitation","volume":"23","author":"Moss","year":"2014","journal-title":"J. Heart Valve Dis."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1331","DOI":"10.1016\/j.echo.2008.09.023","article-title":"Importance of left ventricular longitudinal function and functional reserve in patients with degenerative mitral regurgitation: Assessment by two-dimensional speckle tracking","volume":"21","author":"Lancellotti","year":"2008","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"1436","DOI":"10.1016\/j.echo.2019.07.006","article-title":"Prognostic Value of Global Longitudinal Strain-Based Left Ventricular Contractile Reserve in Candidates for Percutaneous Correction of Functional Mitral Regurgitation: Implications for Patient Selection","volume":"32","author":"Stolfo","year":"2019","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"133998","DOI":"10.1016\/j.ijcard.2025.133998","article-title":"Left ventricular diastolic function modifies clinical outcomes of mild mitral regurgitation","volume":"444","author":"Xie","year":"2026","journal-title":"Int. J. Cardiol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"35079","DOI":"10.1038\/s41598-025-18965-0","article-title":"The prognostic importance of left ventricular diastolic function in primary mitral regurgitation and its relation to structural changes by CMR","volume":"15","author":"Lababidi","year":"2025","journal-title":"Sci. Rep."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/j.echo.2016.01.011","article-title":"Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging","volume":"29","author":"Nagueh","year":"2016","journal-title":"J. Am. Soc. Echocardiogr."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"37","DOI":"10.1093\/eurheartj\/ehaf524","article-title":"Left ventricular hypertrophy and myocardial fibrosis in heart failure with preserved ejection fraction: Mechanisms and treatment","volume":"47","author":"Peikert","year":"2026","journal-title":"Eur. Heart J."},{"key":"ref_55","doi-asserted-by":"crossref","unstructured":"Velidakis, N., Khattab, E., Gkougkoudi, E., and Kadoglou, N.P.E. (2023). Pulmonary Hypertension in Left Ventricular Valvular Diseases: A Comprehensive Review on Pathophysiology and Prognostic Value. Life, 13.","DOI":"10.3390\/life13091793"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.jacc.2019.10.048","article-title":"Exercise Pulmonary Hypertension Predicts Clinical Outcomes in Patients with Dyspnea on Effort","volume":"75","author":"Ho","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"306","DOI":"10.1016\/j.jjcc.2021.09.016","article-title":"The prognostic value of exercise-induced pulmonary hypertension in asymptomatic patients with primary mitral regurgitation","volume":"79","author":"Kadoglou","year":"2022","journal-title":"J. Cardiol."},{"key":"ref_58","doi-asserted-by":"crossref","first-page":"768","DOI":"10.1016\/j.jcmg.2020.12.015","article-title":"Impact of Right Ventricular Dysfunction on Outcomes After Transcatheter Edge-to-Edge Repair for Secondary Mitral Regurgitation","volume":"14","author":"Karam","year":"2021","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"ezae421","DOI":"10.1093\/ejcts\/ezae421","article-title":"Right ventricular to pulmonary arterial coupling as a predictor of survival in patients undergoing mitral valve surgery for mitral regurgitation","volume":"66","author":"Chehab","year":"2024","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"4635","DOI":"10.1093\/eurheartj\/ehaf194","article-title":"2025 ESC\/EACTS Guidelines for the management of valvular heart disease","volume":"46","author":"Praz","year":"2025","journal-title":"Eur. Heart J."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.1007\/s10554-018-1366-5","article-title":"A New modified anthropometric haller index obtained without radiological exposure","volume":"34","author":"Sonaglioni","year":"2018","journal-title":"Int. J. Cardiovasc. Imaging"},{"key":"ref_62","doi-asserted-by":"crossref","unstructured":"Sonaglioni, A., Nicolosi, G.L., Muti-Sch\u00fcnemann, G.E.U., Rispoli, G.A., Lombardo, M., and Muti, P. (2025). Does Preliminary Chest Shape Assessment Improve the Prognostic Risk Stratification of Individuals with Mitral Annular Disjunction? A Case Report and Narrative Review. J. Clin. Med., 14.","DOI":"10.20944\/preprints202502.1923.v1"},{"key":"ref_63","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1007\/s10554-020-02085-z","article-title":"Influence of chest conformation on myocardial strain parameters in healthy subjects with mitral valve prolapse","volume":"37","author":"Sonaglioni","year":"2021","journal-title":"Int. J. Cardiovasc. Imaging"},{"key":"ref_64","doi-asserted-by":"crossref","first-page":"190","DOI":"10.23736\/S2724-5683.23.06446-3","article-title":"Modified Haller Index is inversely associated with asymptomatic status in atrial fibrillation patients undergoing electrical cardioversion: A preliminary observation","volume":"72","author":"Sonaglioni","year":"2024","journal-title":"Minerva Cardiol. Angiol."},{"key":"ref_65","doi-asserted-by":"crossref","unstructured":"Lee, C., Dow, S., Shah, K., Henkin, S., and Taub, C. (2023). Complications of exercise and pharmacologic stress echocardiography. Front. Cardiovasc. Med., 10.","DOI":"10.3389\/fcvm.2023.1228613"},{"key":"ref_66","doi-asserted-by":"crossref","first-page":"689","DOI":"10.1093\/ehjci\/jeab092","article-title":"Real-world performance and accuracy of stress echocardiography: The EVAREST observational multi-centre study","volume":"23","author":"Woodward","year":"2022","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_67","doi-asserted-by":"crossref","unstructured":"Sonaglioni, A., Polymeropoulos, A., Baravelli, M., Nicolosi, G.L., Lombardo, M., and Biondi-Zoccai, G. (2025). Diagnostic Accuracy of Exercise Stress Testing, Stress Echocardiography, Myocardial Scintigraphy, and Cardiac Magnetic Resonance for Obstructive Coronary Artery Disease: Systematic Reviews and Meta-Analyses of 104 Studies Published from 1990 to 2025. J. Clin. Med., 14.","DOI":"10.3390\/jcm14176238"},{"key":"ref_68","doi-asserted-by":"crossref","first-page":"1704","DOI":"10.1007\/s00392-021-01841-y","article-title":"Echocardiographic assessment of mitral regurgitation: Discussion of practical and methodologic aspects of severity quantification to improve diagnostic conclusiveness","volume":"110","author":"Hagendorff","year":"2021","journal-title":"Clin. Res. Cardiol."},{"key":"ref_69","doi-asserted-by":"crossref","first-page":"e297","DOI":"10.5114\/amsad.2020.103032","article-title":"The strain and strain rate imaging paradox in echocardiography: Overabundant literature in the last two decades but still uncertain clinical utility in an individual case","volume":"5","author":"Nicolosi","year":"2020","journal-title":"Arch. Med. Sci. Atheroscler. Dis."},{"key":"ref_70","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1111\/echo.15640","article-title":"Inter-center reproducibility of standard and advanced echocardiographic parameters in the EACVI-AFib echo registry","volume":"40","author":"Santoro","year":"2023","journal-title":"Echocardiography"},{"key":"ref_71","first-page":"30","article-title":"Updated knowledge and practical implementations of stress echocardiography in ischemic and non-ischemic cardiac diseases: An expert consensus of the Working Group of Echocardiography of the Hellenic Society of Cardiology","volume":"64","author":"Kadoglou","year":"2022","journal-title":"Hell. J. Cardiol."},{"key":"ref_72","doi-asserted-by":"crossref","unstructured":"Di Fiore, V., Del Punta, L., De Biase, N., Masi, S., Taddei, S., Rosada, J., Emdin, M., Passino, C., Fabiani, I., and Pugliese, N.R. (2025). Advancing Cardiovascular Risk Stratification and Functional Assessment: A Narrative Review of CPET and ESE Applications. Healthcare, 13.","DOI":"10.3390\/healthcare13131627"},{"key":"ref_73","first-page":"155","article-title":"MitraClip for mitral valve regurgitation and transcatheter aortic valve implantation for severe aortic valve stenosis: State-of-the-art","volume":"17","author":"Tokarek","year":"2021","journal-title":"Postep. Kardiol. Interwencyjnej"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3253\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T14:46:33Z","timestamp":1777041993000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/9\/3253"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,4,24]]},"references-count":73,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["jcm15093253"],"URL":"https:\/\/doi.org\/10.3390\/jcm15093253","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,4,24]]}}}