Non-Holosystolic MR — CW Doppler Tracing & Grading

When This Comes Up

Primary MR — Barlow's spectrum (mitral valve prolapse).
Jet timing is mid-to-late systolic, not holosystolic.
If flail develops → becomes holosystolic. Without flail, the timing stays mid-to-late.

Mental model The orifice is open only during part of systole, so even a sizeable hole leaks for less time.

How to Trace the CW Doppler

Trace what you see on the CW spectral envelope — nothing more.
Do NOT extrapolate the envelope back into early systole.
The mid-to-late onset is the diagnosis — respect it on the trace.

Common error Filling in the missing early-systolic portion to make a "full" envelope → falsely high VTI → falsely high regurgitant volume.

Trace Only What You See — Worked Example

Same patient: PISA radius 0.89 cm, aliasing velocity 45 cm/s, MR peak velocity 4.5 m/s → ERO = 0.50 cm². The only thing that changes between the two panels is how the spectral envelope is traced.

CORRECT — visible envelope only ✓

TVI = 85 cm · R_vol = ERO × TVI = 0.50 × 85 = 43 mL → moderate

WRONG — extrapolated through early systole ✗

TVI = 127 cm · R_vol = 0.50 × 127 = 64 mL → falsely severe

The one rule Your trace must follow the spectral signal — only where signal exists. Extending the line backward through the early-systolic gap inflates TVI and turns a moderate leak into a falsely severe one. Same orifice, same patient, two very different reports.

The ERO ↔ Regurgitant Volume Discordance

For any given regurgitant orifice, volume = orifice × time the orifice is open. A 0.4 cm² ERO that leaks for the entire cardiac cycle delivers more volume than the same 0.4 cm² ERO that leaks for only half the cycle.

	EROA	Time leaking	Regurgitant volume	Concordant?
Holosystolic MR (e.g. flail)	0.40 cm²	Full systole	Severe (~60+ mL)	Yes — both severe
Non-holosystolic MR (MVP, no flail)	0.40 cm²	Half systole	Moderate (~30 mL)	NO — the EROA grade (severe) exceeds the R_vol grade (moderate); that discordance is itself the clue to non-holosystolic timing.

Pattern to recognize In MVP/Barlow's without flail, the EROA looks severe but the regurgitant volume tells a more moderate story. That discordance is itself a clue you are dealing with non-holosystolic MR.

How to Grade Severity

Volume loading on the LV is the actual physiologic problem — the ventricle responds to how much blood is regurgitated per beat, not to the size of the hole at any one moment.

When ERO and regurgitant volume disagree in non-holosystolic MR, grade based on regurgitant volume.
The EROA in this setting overstates severity. Reporting it as the headline number leads to over-treatment.
Document both numbers in the report — but call the severity off the Rvol.

Non-holosystolic MR → severity follows the regurgitant volume, not the EROA.