Transthoracic echocardiography demonstrating myxomatous bileaflet mitral valve prolapse (arrows) in cases 1 (A), 2 (B), and 3 (C). High-velocity mid-systolic spike (lateral annulus, 32 cm/s) in cases 1 (D), 2 (mid-systole, 19 cm/s) (E), and 3 (late systole, 25 cm/s) (F). (G) Normal medial annulus systolic velocity, case 1. (H) Tugging of the posteromedial papillary muscle by prolapsing leaflets (arrow), case 4. (I) Late-peaking systolic tissue velocity spike of 24 cm/s, case 4. (J) Pickelhaube, spiked German military helmet (reprinted with permission from the collection of Peter Suciu).