A 42-year-old woman with a history of rheumatic fever in her teens and a known murmur for the past ten years presents with a progressively decreasing exercise tolerance for the past four years, and a recent admission to hospital for congestive heart failure:

• Sinus rhythm
• Biatrial enlargement
• Right axis deviation
• Right ventricular hypertrophy

The echocardiogram demonstrated the presence of severe mitral stenosis (mean valve area 0.6 cm², mean mitral valve gradient 22 mmHg) and mild aortic regurgitation. The posterior mitral valve leaflet was restricted, the anterior leaflet had good mobility, and there was no calcification. There was pulmonary hypertension (RV systolic pressure 75 mm Hg), and the right ventricle was mildly dilated, with good systolic function. Both atria were dilated. The patient underwent successful mitral valvuloplasty with good functional improvement.