This patient had hypertrophic obstructive cardiomyopathy with significant left ventricular outflow tract obstruction.

The left superior pulmonary vein is also seen.

The atrioventricular valves remain on the same plane.

The myocardium has a sparkling appearance. There is also similar thickening of the interatrial septum. Mild generalized thickening of the valves is present.

Commonly, contrast is needed to visualize the spade-like appearance of the LV in these patients.

Note the presence of the native apically displaced tricuspid valve.

There is atrialization of the basal to mid-right ventricle.

The apical position of the tricuspid valve identifies the hypertrophied systemic ventricle as the morphologic right ventricle.

An echodensity can be seen prolapsing across the tricuspid valve. The right ventricle is dilated with McConnell's sign suggestive of acute pulmonary embolism.

McConnell's sign present in the setting of acute pulmonary embolism.

Marked left atrial dilatation is seen.

A large chronic (echogenic) laminar apical thrombus is seen when the image is tilted to provide a “non-foreshortened” view illustrating the importance of probe position to adequately evaluate the left ventricular apex especially in dilated hearts.

There is a large proportion of the right ventricle that is "atrialized."

Note the gross malcoaptation of the tricuspid valve leaflets secondary to annular dilatation.

Marked right heart dilatation with severe right ventricular hypokinesis. A small underfilled left ventricle with evidence of compression from pericardial effusion is seen.

These findings are consistent with pericardial tamponade.

There is also right ventricular (RV) dilation.

Note the large pericardial effusion and thrombus in the pericardial space.

The left atrial and left ventricular cavities are small in comparison.

This patient was found to have septic emboli seen on a subsequent chest computed tomography scan.

Note marked displacement of the mitral annulus during diastole.

Notice significant shadowing from the bioprosthesis struts affecting assessment of color Doppler in the left atrium. There is systolic turbulence consistent with mitral regurgitation seen in the center-posterior left atrium where the beam is unaffected by shadowing.

The mass appears to originate from the anterior mitral valve leaflet. Note no significant mitral valve regurgitation is seen.

Overall mass is increased consistent with concentric left ventricular hypertrophy.

Marked mitral valve calcification with relative sparing of the leaflet tips.

Overall mass is markedly increased consistent with eccentric left ventricular hypertrophy.

Notice the apical focus position to destroy the bubbles in the apex and decrease contrast attenuation.

These two-dimensional features are associated with ischemic mitral valve regurgitation.

Unlike organized laminar left ventricular thrombus, this thrombus is protuberant.

Note the “spade”-shaped left ventricular cavity.

An echodensity is noted in the left ventricular apex concerning for thrombus.

The pulmonic valve leaflets are barely visible but appear flail.

The pulmonic valve leaflets are difficult to visualize.

Note the presence of severe right heart dilatation.

The entrance of the inferior vena cava and coronary sinus can be seen in the right atrium.

The left ventricle is seen under the right ventricular outflow tract.

The patient also has systolic anterior motion of the mitral valve and is expected to have left ventricular outflow tract obstruction.

There is exaggerated motion of the interventricular septum that bows towards the left.

The Impella cannula is seen across the aortic valve into the LV. There is again color Doppler artifact seen by the cannula.

Left atrial compression from the effusion is seen. Also note the large left pleural effusion that tracks posterior to the descending aorta in contrast to the pericardial effusion.

There is moderate global left ventricular systolic dysfunction.

Note the reverberation and shadowing artifact posterior to the valve.

In contrast to rheumatic disease there is calcification seen extending from the annulus toward the leaflet tips with severe restriction of motion.

Note the "busy" left atrium with baffle seen. Also the aorta and pulmonary artery are parallel to each other in this view.

Notice reverberation artifact of the sub-valvular apparatus posterior to the inferolateral wall.

The mitral valve leaflets have normal thickness and no flail segments.

Note the unusual tethering of the anterior and posterior mitral valve leaflets to a single papillary muscle.

Aortopathy associated with bicuspid aortic valve is also seen with dilatation of the proximal ascending aorta with relative sparing of the sinuses and sinotubular junction.

Reverberation artifact from leaflet motion can be seen as well as microcavitary bubbles (occasionally present without pathological consequence).

There is also continuous machinery like color Doppler artifact due to the inflow cannula.

Note doming of the aortic valve leaflets.

Note also the redundant mitral valve leaflets with prolapse.

Doming of the aortic valve consistent with bicuspid aortic valve. There is also narrowing of the sinotubular junction of the aorta with dilatation of the proximal ascending aorta.

These findings are consistent with rheumatic mitral valve disease.

Note the narrow “neck” typical of a pseudo-aneurysm.

A large pericardial and pleural effusion is also seen.

The posterior mitral valve leaflet appears flail with a linear mobile echodensity at the leaflet tip consistent with ruptured chordae tendineae.

Note unusual "en face" orientation of the prosthesis.

Note the "speckles" in the anterior pericardial space and lack of posterior pericardial effusion suggesting that this is fat rather than effusion.

The right ventricle is now spherical and the left ventricle is “D-shaped” with interventricular septal flattening in both systole and diastole.

Further imaging studies demonstrated this to be metastatic disease to the pericardium.

The left atrium is furthest from the probe with the descending thoracic aorta seen behind it.

A large pleural effusion is also seen.

A large pericardial effusion is seen causing diastolic compression of the left ventricle while the right ventricle remains dilated secondary to right ventricular pressure overload.

Note the characteristic flattening of the affected left ventricular wall in diastole.

Entry of the bubbles into the left atrium can be seen from the left superior pulmonary vein.

Note the bubbles appear in the left heart and then quickly clear with subsequent heart beats.

The bubbles however arrive late in the left atrium and continue to arrive long after right heart opacification has diminished. These findings are consistent with an extra-cardiac shunt in this patient with hereditary hepatic telangiectasia. The right heart size is normal.

Over time the bubbles in the left heart decrease in intensity with the right heart. Right heart dilatation is present.

Apical long-axis view with biphasic response seen in the left ventricular apex and akinesis of inferolateral and anteroseptal walls at peak dobutamine dose suggestive of multivessel coronary artery disease.

Apical two-chamber view in the same patient with biphasic response seen in the left ventricular apex as well as akinesis of the inferior and anterior walls at peak dobutamine dose suggestive of multivessel coronary artery disease.

Apical four-chamber view with akinesis of the basal to mid-inferoseptal wall. Baseline left ventricular apical akinesis improves with low-dose dobutamine and worsens with increasing doses (biphasic response) suggestive of significant left anterior descending disease.

In the same patient severe hypokinesis to akinesis of the mid-inferior and inferoseptal walls is seen.

In the same patient normal endocardial thickening is seen in the parasternal long-axis view.

Apical two-chamber view in the same patient with severe hypokinesis of the basal to mid-inferior wall.

Apical four-chamber view with akinesis of the basal to mid-inferoseptal wall.

There is a unilateral eccentric jet near the anterior portion of the suture ring concerning for perivalvular regurgitation.

Initial injection of agitated saline is seen to ensure the pericardiocentesis needle is correctly positioned in the pericardial space.

Note mild aortic valve regurgitation is present.

The systolic blood pressure is 115 mmHg.

The systolic blood pressure is 205 mmHg.

The mitral regurgitation appears to originate in the mid-portion of the anterior mitral leaflet with a proximal isovelocity surface area seen on the left ventricular surface of the leaflet.

Note proximal isovelocity surface area formation on the left ventricular surface of the anterior mitral valve leaflet.

Note the Nyquist limit scale is not set at the recommended levels and may exaggerate the color Doppler appearance of tricuspid regurgitation.