This 57-year-old woman had rheumatic fever at age 17. During the past year, her exercise tolerance has severely decreased due to fatigue and dyspnea:

• Sinus rhythm, 70/min
• Left atrial enlargement
• Right axis deviation
• Right ventricular hypertrophy

The patient had been known to have mitral stenosis for many years. Investigations revealed severe mitral stenosis and regurgitation, pulmonary hypertension, and right ventricular hypertrophy and dilation. The patient was admitted to hospital with symptoms and signs of congestive heart failure.