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hi this is Peter Ekman a heart failure cardiologist from the Minneapolis Heart Institute I appreciate the opportunity to present today my disclosures involve Abbott Laboratories Medtronic and Dax or all funds are donated and I have no control over those funds Iamp;#39;d like to start with a patient scenario a 55 year old woman with mildly decreased ejection fraction dilated ventricles mitral regurgitation she has no coronary disease but paroxysmal afib sheamp;#39;s managed medically with some improvement in her left ventricular size but unfortunately by the age of 75 when we meet her her ejection fraction has declined her ventricle has dilated and she now has severe mitral regurgitation with nyj functional class 3 symptoms she has a modest meet pressure gradient an echo I think you can appreciate that a right ventricular function is a bit impaired but not terrible her LV function is poor and on color Doppler we see her mitral regurgitation severe in clinic she has hypotension heart r