In an asymptomatic patient with mitral regurgitation, how can echocardiography be used to determine the optimal time for mitral valve replacement?

The goal is to replace the valve before irreversible left ventricular dysfunction develops. Patients with mitral regurgitation should exhibit hyperdynamic left ventricular function owing to unloading of the ventricle into the low-pressure left atrium. Normal fractional shortening actually indicates suboptimal ventricular performance. Therefore, if the ejection fraction falls below 60% or the end-systolic dimension is more than 45 mm, valve replacement should be considered.