A 76-year-old woman had repeated hospital admissions for volume overload, respiratory failure, prolonged intubations, atrial fibrillation, and tachy-brady syndrome.

On repeated transthoracic echocardiograms (TTE), she has a normal to hyperdynamic left ventricular (LV) systolic function and variably moderate or severe pulmonary hypertension. She has difficult transthoracic images (Figs. 74-1, 74-2, 74-3 and 74-4 and Videos 74-1 and 74-2).