Combined mitral and pulmonic stenosis.

A 56-year-old Caucasian woman was well until the age of 25, when she had a full-term uncomplicated pregnancy. Several days following delivery, she first developed left precordial chest pain and was told by a physician that she had rheumatic heart disease with mitral stenosis. She had no history of rheumatic fever. The chest pain recurred intermittently for several days. She then became asymptomatic until the age of 32, when during the course of her second pregnancy, she first developed palpitation. The palpitation occurred infrequently at first, then with increasing frequency in the past 10 years, often 2 to 3 times per week with individual episodes lasting from several minutes to several days. On various occasions, they have been recorded by electrocardiogram as showing atrial tachycardia and atrial fibrillation. Quinidine was variably effective in terminating these paroxysmal attacks. In April 1952, she had an initial episode of pulmonary edema. She was awakened from sleep with palpitation and dyspnea. Moist rales were present throughout both lung fields. She was treated with morphine sulfate and quinidine, and the pulmonary edema subsided as her heart rate slowed. An electrocardiogram taken after this episode showed first degree heart block (P-R interval of 0.22 second). In April 1953, and again in March 1954, she had episodes of pulmonary edema arousing her from sleep and associated with marked tachycardia. As the cardiac rate returned to normal, the pulmonary edema subsided. In December 1954, she had her first documented attack of paroxysmal atrial flutter, with the electrocardiogram showing a 2 :1 atrial flutter. This