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I think my my job is the easiest job just Im presenting a case and who are listening to your opinion we are the main aim is to define those patient exactly patient with advanced heart failure and to explore the therapeutic options for them 52 year old man refer to our heart failure clinic as a case of advanced heart failure in July 2014 his known case of non ischemic ballot card emergency for at least three years before presenting to us was the ejection fraction 10% and dilated LV cath one year ago showed normal cronies and he had CRT D six month ago in the referring center and had comer abilities in the form of diabetes mellitus and hypertension his symptoms included exertional Disney and fatigue he is unable to to climb one flight of stairs without this without this Nia he has occasional pain D and orthopnea Nia class three and four he has also orthostatic business and he has lower limb BBA laterally ascites all up to the level of scrotal edema I can see Anna circa for the last two