A 40-year-old man who has had a previous AVR 10 years ago and PPM insertion following complete heart block post-operatively. He had a pacemaker upgrade to a CRT device a year ago. He now re-presents with severe shortness of breath and has been referred for assessment for LVAD implantation. His echo is shown in Figures 19.1, 19.2, 19.3, 19.4 and 19.5 and Videos 19.1, 19.2, 19.3, 19.4, 19.5, 19.6, 19.7, 19.8, 19.9 and 19.10.