Symmetric tenting due to ischemic LV dilatation. These TTE images were obtained from a 72 year-old male with severe multivessel coronary disease and an advanced ischemic cardiomyopathy with LV ejection fraction of 14% and an LV end-diastolic dimension of 71 mm prior to coronary bypass surgery. A phenotype of symmetric tethering is depicted by these mid-systole images obtained from the apical three chamber view (A) and apical four chamber view (B). The parasternal long axis view is shown as panel A of Figure 4. Measured in the parasternal long axis image, the tenting height was 1.4 cm, the tenting area was 4.0 cm2 and the tethering angles β and α were equal. MR severity was graded as trace. Compared to the patient described in Figure 3, the same tenting height and tenting area were associated with markedly distinct CIMR severity, reiterating that tenting phenotype is of utmost importance in determining severity.