A 61-year-old Caucasian man with recently diagnosed eosinophilic chronic myelomonocytic leukemia presented with fevers and right-sided heart failure that failed to respond to diuretics. He denied any history of travel to the tropics. Exam was remarkable for pallor, edema and S4 gallop. He had leukocytosis (54 × 10⁹/L; 55% eosinophilic predominance), anemia and thrombocytopenia (3 × 10⁹/L). Echocardiogram showed grade 2 diastolic dysfunction, moderate mitral regurgitation and elevated right heart pressure. There was apical left ventricular thickening concerning for tumor, laminated thrombus or focal hypertrophy (Figure 1, Movie 1). Given severe thrombocytopenia, endomyocardial biopsy and anticoagulation were contraindicated. Cardiovascular magnetic resonance (CMR, Figure 2, Movie 2, 3) showed increased focal apical wall thickness of 22 mm with hypokinesis of this segment (Figure 2A). First pass perfusion revealed hypoperfused apical and lateral endocardium with a layer of superimposed clot (Figure 2B). Late gadolinium enhancement images showed hyperintense apical fibrosis extending from the endocardium to mid myocardium, covered by a cap where laminated clot was present producing a “double V” sign (Figure 2C). This was also confirmed on the 3-chamber early gadolinium enhancement image with long TI of 600 ms that showed apical thrombus distinct from the underlying myocardium (Figure 2D).