Clinical introduction A 21-year-old, previously healthy, woman presents to the emergency department with 2 months of dyspnoea on exertion. She is short of breath walking up a flight of stairs. She has a history of intravenous drug use and takes no medications. Family history is negative for cardiac disease. Heart rate is 110 bpm and blood pressure is 125/55 mmHg. She has an elevated jugular venous pressure, bibasilar rales, a soft S1 and a systolic in addition to a diastolic murmur. Shortly after initial presentation in the emergency department, she is intubated for respiratory failure. A transthoracic echocardiogram is obtained (figure 1).

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Figure 1

(A) M-mode recording of the mitral valve. (B) Continuous-wave Doppler of transmitral flow.

Question In addition to abstinence from drug use, which of the following is the most appropriate definitive therapy?

1. Mitral valve repair

2. Aortic valve replacement

3. Balloon mitral commissurotomy

4. Dual-chamber pacemaker

5. Septal myectomy

Question