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Sixteen patients with rheumatic heart disease and pure mitral stenosis, studied by cardiac catheterization, are presented to illustrate the relative importance of mitral block and myocardial insufficiency in this disease. Analysis of hemodynamic data permitted a separation of those patients with predominantly mechanical mitral block from those in whom myocardial insufficiency appeared to be the predominant lesion. The importance of recognizing the existence of the latter group is emphasized, since commissurotomy will not be of benefit in such cases.C IRCULATORY dysfunction in rheumatic heart disease has long been recognized as springing from at least two main sources, the mechanical difficulties imposed by valvular lesions and the insufficiency of the myocardium itself. This insufficiency may result from longstanding strain inflicted on the cardiac muscle by altered valvular function or, independently of mechanical cause, may occur consequent to intrinsic myocardial damage from the rheumatic process. Our understanding of cardiac function in rheumatic patients would be increased if one could separate the mechanical from the myocardial components in order to investigate further the disability these subjects experience. The surgical approach to rheumatic mitral stenosis, attacking as it does only the mechanical features of valvular lesions, affords an opportunity to study this problem. Furthermore, if it can be shown that myocardial insufficiency exists as a separate dysfunction, it behooves the physician and surgeon to be certain that the prospective candidate foi mitral commissurotomy is suffering from a

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