His ECG is shown again here. The rhythm is sinus and the PR interval and QRS duration are normal. The P waves appear notched with a prominent negative component in lead V1, suggesting possible left atrial enlargement. The tall R waves in leads V5 and V6 (35 and 25 mm respectively) and the sum of the R wave in V6 and the S wave in V1 (43 mm) are consistent with left ventricular hypertrophy. These findings, coupled with the murmurs and the history of rheumatic fever suggest rheumatic valvular disease with both mitral and aortic insufficiency and possible aortic stenosis. The echocardiogram confirmed the diagnoses of aortic and mitral insufficiency, but found no aortic stenosis .