A 76-year-old man was admitted to hospital for a transient ischaemic attack. The electrocardiogram showed atrial fibrillation and biphasic T-waves in the precordial leads. Echocardiography disclosed severe asymmetrical apical hypertrophy with a typical ‘ace-of-spades’ configuration and a maximum left ventricular wall thickness of 21 mm ( Fig. 1 , Video 1 ). Although the apical myocardium appeared compact on two-dimensional echocardiography, colour Doppler revealed large linear flows at the left ventricular apex ( Fig. 2 , Video 2 ), which broadened the differential diagnosis with deep apical recesses or left ventricular non-compaction. Contrast echocardiography was performed to further clarify the diagnosis, but failed to demonstrate any recesses within the apical myocardium ( Fig. 3 , Video 3 ).
