<prompt> A 40-year-old woman had several episodes of rheumatic fever as a child. She is currently afebrile and feels well, and has come to a hospital for monitoring echocardiography. Which of the following findings would MOST likely be seen in this patients mitral valve?Ballooning of valve leafletsFibrous bridging between thickened, calcified leafletsIrregular beads of calcification in annulusLarge bulky vegetation with adjacent leaflet perforation  <response>: Acute rheumatic fever is a multisystem inflammatory disease that can follow group A streptococcal pharyngitis. The hea is a primary target of this disease and may be damaged sufficiently to develop permanent sequelae. The most impoant of these sequelae is chronic rheumatic hea disease with valvular damage. The damage most often involves the mitral andor aoic valves. The resulting thickened, blunted cardiac valve leaflets, often with fibrous bridging between valve leaflets and calcification, frequently take on a fish mouth or button hole stenotic morphology.Good to know:Associate ballooning of valve leaflets with mitral valve prolapse.Associate irregular, bead like calcifications on the annulus with calcification of the mitral annulus, seen in elderly individuals.Associate large vegetations and leaflet perforation with acute bacterial endocarditis, which usually involves healthy, rather than previously damaged, valves. Ref: Carapetis J.R. 2012. Chapter 322. Acute Rheumatic Fever. In D.L. Longo, A.S. Fauci, D.L. Kasper, S.L. Hauser, J.L. Jameson, J. Loscalzo Eds, Harrisons Principles of Internal Medicine, 18e. 