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Rheumatic heart disease (RHD) continues to be a major health problem in developing countries. The burden of disease in many countries, especially those of Oceania, is very high and is still the leading cause of heart-related deaths. Several factors contribute to the prevalence of RHD in the Pacific Basin including poverty, poor access to care, distance for travel, and limited resources. The Pacific Island Health Care Project (PIHCP) at Tripler Army Medical Center (TAMC) is a unique program which provides indigenous, medically under-served peoples in the United States Associated Pacific Islands (USAPIs) with definitive medical and surgical care. The program has been an important source of patients to enhance Graduate Medical Education (GME) at TAMC. Beginning in 1998, a secure, Web-based, store-and-forward telemedicine network was developed. It was ultimately deployed to 11 sites in the USAPIs. This unique platform has facilitated the selection and definitive care of Pacific Islanders at TAMC. The purpose of this study was to review our experience with RHD in patients referred from the USAPIs utilizing a unique telemedicine system. All patient records that were archived in the PIHCP database were retrospectively reviewed for the diagnosis of RHD from 1998 (telemedicine program began) to 2006. Descriptive analysis of the data is displayed in a tabular format. Of the 150 patient consults with RHD in the PIHCP 76 were accepted for care at TAMC and 74 came to Honolulu. Most patients were younger than 40 years of age. Almost all patients evaluated at TAMC had mitral valve involvement, and 81% of patients underwent a surgical procedure to correct the valvular disease. Our experience with RHD and its management illustrates a number of challenges that must be addressed by those who attempt to provide technically advanced care to persons from the developing world. In the case of RHD, patient selection, choice of intervention, and early return of the patient home are critical to the success of any such program. Despite these problems the PIHCP has restored many patients to health and returned them to their island homes as contributing members of society. [ABSTRACT FROM AUTHOR]