**VALVE CASE OF THE WEEK**

@BrHeartValveSoc

Right, hope you're all caught up on those #ESCCongress presentations!! As there was no case last week, we'll have more than 1 poll at the end of this case!

This one is all about "functional" mitral regurgitation (MR)

Some of you will have seen the recent discussions in which FMR is now subdivided into AF-MR and VF-MR, depending on whether it is pathology affecting the atrium or ventricle that leads to MR. This week's case focuses on AF-MR.

Pt in 80s. Very fit & healthy, walks miles daily.

Originally referred 6yrs ago with new AF. Echo (below) showed dilated LA with mild MR. AF rate slow so follow-up arranged...and have seen pt annually since. Totally asymptomatic, can still walk miles without difficulty.

Here is the echo from 2yrs later...

And 2 yrs later again...

And then this year...AP4Ch

And AP3Ch...

Here are the TR Doppler traces from this year (right) and 4yrs ago (left)... RVSP was ~20mmHg originally 6yrs ago.

Also, LAVI has INCREASED with time from 80ml/m2 to 115ml/m2 and RV basal diameter has increased from 43mm to 51mm.

But still totally asymptomatic and walking miles

So...how do you manage this sort of scenario? In a pt in their 80s with asymptomatic functional MR, I think valve surgery is a big call. But here are 2 polls, let's see what everyone thinks...

Poll 1: Pretend this patient has worsening exertional dyspnoea. Otherwise fit, no major comorbidities. Would you say:

Poll 2: Now pretend this ASYMPTOMATIC pt is actually 62, not 82. AF-MR with dilated RV and pulmonary hypertension. Does this change the equation? Pre-emptive intervention to prevent HF? Or not?

@BSEcho @ASE360 @WessexSpRs @BJCA_Women_LTFT @TheBJCA @global_wic @echo_stepbystep @MadalinaGarbi @JGrapsa @drkirmani @brwcole @SineadHughes19 @coolo_breezo @BadriChandrase5 @dorsetcardio @DrChrisMcAloon @LynnGreigMiller @drstevenwhite @NMerke @iamritu @purviparwani @aayshacader

@HJarrett_MD @heartdockumar @DocStrom @jdrwilcox @RODRIGOVISCONT1 @RobertoC8a @DrHaniMahmoud @denisamuraru @dr_chrisallen @hannahcvimaging @DrDanAugustine @DrDavidWarriner @KMJohnChan @M_Pompeu_Sa_MD @Ph_Bertrand @rachkataria

#cardiotwitter #echofirst #ACCFIT #EACVI

@FGraziani_Grace @kristelly79 @manasinha @carpenter_jp @TharushaGunawa4 @DrNathan001 @MayooranShan always, apologies to those I forgot to tag...please do feel free to share / RT.

As usual, will update tomorrow once polls end!