A 41-year-old man is admitted with pneumonia and congestive heart failure. On examination evidence of valvular heart disease is discovered:

• Sinus rhythm
• Left atrial enlargement
• Right ventricular hypertrophy
• ST and T wave abnormality, consider anterolateral ischemia

On admission the patient had evidence of pneumonia and congestive heart failure. He was severely hypoxic and required intubation and ventilation. An echocardiogram demonstrated severe mitral stenosis (mitral valve area 0.6 cm/squared), pulmonary hypertension and right ventricular hypertrophy and dilatation. He was vigorously treated, but his condition remained critical. He underwent successful urgent balloon mitral valvuloplasty followed by gradual satisfactory recovery.  

The ST and T wave abnormality may be due to the heart failure and hypoxia. Following his recovery the patient underwent non-invasive investigation that showed no evidence of exercise-induced ischemia.