This is a prospective, multi-centre observational study looking at baseline, one year, and two year changes in cardiac function compared to clinical outcomes in participants with rheumatic heart disease and examining whether CMR can predict outcomes better than echocardiography or exercise stress testing alone. This will aim to enrol 45 asymptomatic patients with RHD from CMC Vellore (15 severe MS, 15 moderate MMVD, 15 severe MR).

The date of birth, body weight, height, gender, race and all medications will be collected. The medical history of the participant will also be recorded. Heart failure related hospitalisations, new symptoms, new atrial fibrillation and strokes will be recorded. Participants will complete the EQ-5D-5L Health Questionnaire at regular intervals. Blood will be drawn and processed to determine the creatinine, haemoglobin, haematocrit, CRP and BNP. A regular and comprehensive TTE with 3D is standard of care for every participant with mitral valve disease. LV strain, left atrial LA ejection fraction and LA systolic function requires no additional views to the standard echocardiogram for comprehensive mitral valve assessment. Images for these novel indices will be assessed offline using customized software. An exercise stress test for evaluation of symptoms and changes in pulmonary pressures will be performed yearly.

The minimum target number of participants for each group in this study is 20. This is based upon power calculations showing that 16 patients would be needed to show a 10% reduction in exercise treadmill time with an α of 0.05 and 80% power.