## 5 Conclusions  
Our findings collectively contribute to a better understanding of hemodynamic forces in MR patients. This study led us to the conclusion that HDF can be used as a powerful metric to evaluate MR. Evaluating the MR severities requires a multi-parametric approach, and HDF can serve as an additional potential marker that reveals the association with the LV function. This study strongly suggests HDF as a confounder of severity stratification on MR. Systolic RMS B-A [B = 3.253, 95% CI (1.204-5.301), \(p\)-value = 0.003] and diastolic RMS S-L [B = 5.413, 95% CI (0.227-10.6), \(p\)-value = 0.029] have emerged as promising indicators. These findings enhance our understanding of LV flow dynamics in MR, advocating for the adoption of HDF as a key tool in MR evaluation.  
The following supporting information can be downloaded at: [[https://www.mdpi.com/article/10.3390/app14198577/s1](https://www.mdpi.com/article/10.3390/app14198577/s1)]([https://www.mdpi.com/article/10.3390/app14198577/s1](https://www.mdpi.com/article/10.3390/app14198577/s1)), Table S1: Comparison of AVG HDF (mN/mL), RMS HDF (mN/mL), and RMS ratio between controls and MR patients with preserved EF; Table S2: Differences in HDF and LV function between controls and mitral severities; Table S3: Correlation between LV function and HDF; Table S4: Spearman's rank order correlation between mitral severity and HDF.  
Conceptualization, M.G.S. and J.G.; methodology, M.G.S. and J.G.; validation, M.G.S., C.A. and J.G.; formal analysis, M.G.S.; investigation, M.G.S. and J.G.; resources, J.G., L.K. and M.G.S.; data curation, M.G.S. and J.G.; writing--original draft preparation, M.G.S.; writing--review and editing, M.G.S., C.A., J.G. and L.K.; visualization, M.G.S.; supervision, J.G., and L.K.; project administration, M.G.S., J.G. and L.K.; funding acquisition, L.K., J.G. and M.G.S. All authors have read and agreed to the published version of the manuscript.  
This research was funded by The University of Calgary; J.G. start-up funding (#11022618 and #11021988). We acknowledge the support of the Natural Science and Engineering Research Council of Canada /Conseil de recherche en science naturelles et en genie du Canada, RGPIN-2020-04549 and DGECH-2020-00204. NSERC Alliance--Alberta Innovates Advance Program (#232403115). The study was supported by The University of Calgary, Department of Biomedical Engineering, Graduate Program, and Libin Cardiovascular Institute (Anne M. Gillis Award for Cardiovascular Research) (to M.G.S).  
The Conjoint Health Research Ethics Board approved the study at the University of Calgary (REB#13-0902) (May 2024). The study was conducted according to the Declaration of Helsinki.  
**Informed Consent Statement:** All subjects provided written informed consent.  
**Data Availability Statement:** The anonymized data are available upon request from the corresponding author.  
**Acknowledgments:** The authors thank all investigators, clinical staff, and participants of the Cardiovascular Imaging Registry of Calgary (CIROC) for their valuable contributions. We thank [PERSON] and [PERSON] for sharing their tool for calculating HDF.  
**Conflicts of Interest:** The authors declare that the research was conducted without any commercial or financial relationships that could be constructed as a potential conflict of interest.