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Purpose: The aim of the study was to assess the influence of semi-supine exercise echocardiography (ExE) on moderate ischemic mitral regurgitation (IMR) in patients (pts) with heart failure (NYHA II/III) after ST elevation myocardial infarction (STEMI) treated with primary angioplasty (PCI).Materials and methods: We analyzed 58 pts (M-39; 63±10 year) after STEMI, complicated with heart failure and moderate IMR in 12 month follow up. Size of IMR, ejection fraction (EF) and transtricuspid pressure gradient (TVPG) were assessed using 2D and Doppler echo at rest and during exercise. Effective regurgitation orifice (ERO) was used for quantitative IMR assessment (moderate ≥10-20, severe ≥ 20 mm2). As clinically significant we established change of IMR from moderate to severe during ExE.Results: In all group of pts the ERO of IMR increased from 14±2,3 mm2 at rest, to 22,7±6,7 mm2 at peak exercise (p<0,0001), TVPG from 25,1±4,7 mmHg at rest, to 33,3±7,4 mmHg at peak exercise (p<0,0001). In 29 pts we observed increase of ERO above 20 mm2 during ExT (50%). In this group there was a positive, significant correlation between exercise-induced changes in ERO and TVPG (r=0.58, P<0.001). ExE-induced changes in ERO were also related to ExE-induced changes in coaptation high (r= 0.72, P=0.001), tenting area (r =0.68, P=0.002), and wall motion score index (r=0.41, p=0.01). The ERO decreased in 4 pts. ECHO parameters at rest in whole pts (gr.1) and in pts with increase of ERO ≥ 20 mm2 (gr.2) are shown in table 1.Conclusions: 1. ECHO evaluation at rest underestimates the severity of IMR.2. ExE changes in IMR severity are strictly related to ExE changes in mitral deformation and presence of recruitable contractile reserve.3. A moderate degree of mitral regurgitation at baseline can be associated with large dynamic changes, explaining the clinical spectrum of symptoms.