Baylor University Medical Center Proceedings January 2014, Volume 27, Number 1 | Page 43

waves are more often associated with atherosclerotic cardiac disease (1). Although any atrial fibrillation is a marker for left atrial enlargement, coarse atrial fibrillation appears to be a more specific marker (1, 3). This patient had longstanding rheumatic heart disease with more severe mitral stenosis than regurgitation and significant aortic stenosis and regurgitation. The mitral disease was the major cause of his left atrial enlargement and atrial fibrillation. The aortic valve disease was the main reason for his left ventricular hypertrophy, manifested in the electrocardiogram by RV5 > 26 mm (2.6 mV), RV6 > 20 mm, SV1 ≥ 30 mm, SV1 + RV5 or RV6 > 35 mm, and SV2 + RV5 or RV6 > 45 mm (4). The repolarization changes in leads V4 to V6 could be due to left ventricular hypertrophy, but the essentially isoelectric J points, rounded sagging of the ST segments, and small but upright T waves also suggest the effects of digoxin, a drug he was taking. Because of symptomatic congestive heart failure, the patient underwent mitral and aortic valve replacement. He had an uneventful postoperative course. 1. Thurmann M, Janney JG Jr. The diagnostic importance of fibrillatory wave size. Circulation 1962;25:991–994. 2. Thurmann M. Coarse atrial fibrillation in congenital heart disease. Circulation 1965;32:290–292. 3. Peter RH, Morris JJ Jr, McIntosh HD. Relationship of fibrillatory waves and P waves in the electrocardiogram. Circulation 1966;33:599–606. 4. Milliken JA, Macfarlane PW, Lawrie TDV. Enlargement and hypertrophy. In Macfarlane PW, Lawrie TDV, eds. Comprehensive Electrocardiology. Theory and Practice in Health and Disease, vol. 1. New York: Pergamon Press, 1989:631–670. Avocations A young leopard in South Africa. Photo copyright © Jed Rosenthal, MD. Dr. Rosenthal is a cardiologist in Dallas, Texas (e-mail: [email protected]). January 2014 Irregular cardiac rhythm with combined rheumatic mitral stenosis and aortic stenosis 41