Real 3D echocardiography, MRI, and tissue doppler imaging. (A) 2D echocardiogram in the short-axis section of the left ventricle demonstrated uncommonly enlarged papillary muscles (A: anterolateral papillary muscle, P: posteromedial papillary muscle, ACC: accessory papillary muscle). (B) Real time 3D Echocardiography demonstrated that LV mid-cavity was almost obliterated during end-systolic phase from five chamber view (Additional file 1, movie 1). A: anterolateral papillary muscle, LA: left atrium, LV: left ventricle. (C) Contrast-enhanced MRI from LV short-axis showed two large papillary muscles as well as adjacent abundant muscular trabeculae producing mid-cavity obstruction during systolic phase. (D) MRI from long-views showed anterolateral papillary muscle squeezing left ventricular outflow tract against LV septum during systolic phase. High temporal resolution Tissue Doppler Imaging showed markedly diminished diastolic mitral annulus relaxation velocities, 1.8 cm/sec for basoseptal (E) and 4.3 cm/sec for basolateral segments (F).