Our patient is a 45 year old woman with a chief complaint of progressive shortness of breath, fatigue, and palpitations of 6 months duration. The pertinent features of her history include the following: she had rheumatic fever as a child with a heart murmur since then. She was treated with antibiotics as prophylaxis for acute rheumatic fever. Fatigue and dyspnea on exertion began several years ago and improved with digitalis, diuretics, and salt restriction. While on therapy her symptoms recurred along with intermittent palpitations and paroxysmal nocturnal dyspnea. There is no history of recent fever or chills, chest pain or syncope. She has had no recent pregnancy or history of cerebrovascular events.