Asymptomatic patient: The current opinion is that in asymptomatic patients with left ventricular dysfunction and severe MR surgery should not be delayed. The echo cardiographic assessment of mild LV dysfunction is defined as EF 0.5 to 0.6 and left ventricular end systolic dimension 45 to

50mm. Similarly, moderate LV dysfunction is EF 0.3 to 0.5 and LV end systolic dimension is 50 to 55mms. Severe dysfunction is when EF is < 0.3 and end systolic LV dimension > 55 mms. When there is LV dysfunction all attempts should be made to repair the valve or if that is not possible, do a conservative valve replacement preserving both leaflets and chordae and papillary muscles. A patient need not be rejected for surgical repair even if the ejection fraction is < 0.3 and left ventricular end systolic dimension is more than 55 rnm.

Asymptomatic patient with normal LV function and severe MR, should be followed up nledically. In an experienced centre with good success in mitral valve repair, the current opinion is that mitral valve 'repair should be advised. If such a patient is in atrial fibrillation, mitral valve repair should be combined with surgery for AF'(C0X 111 -MAZE operation).

In cases of ischaemic mitral regurgitation, a coronary a-teriogram is always done and coronary artery bypass is combined with mitral valve repair. All patients above 40'ye&s should have coronary ailgio before any valve surgery.