This 78-year-old woman with a previous history of rheumatic fever and an associated heart murmur presents to the hospital in severe congestive heart failure:

• Atrial fibrillation – Ventricular rate 84/min
• Right axis deviation
• Incomplete right bundle branch block (iRBBB)
• Biventricular hypertrophy

Right axis deviation, iRBBB, and 10 mm R’ in V1 suggests right ventricular hypertrophy. The R wave in V5 > 26 mm suggests left ventricular hypertrophy.

The echocardiogram showed severe mitral stenosis and moderately severe mitral regurgitation. The right ventricular systolic pressure was estimated to be 55 mmHg. There was right ventricular hypertrophy and severe tricuspid regurgitation.