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so this is a a didactic focused on cardiac resynchronization therapy for heart failure and weamp;#39;ll go to next slide here alright so this is a case vignette this is actually someone I took care of during fellowship a 52 year old woman with a history of idiopathic cardiomyopathy and she came into clinic exertional dyspnea and fatigue with minimal activity so sheamp;#39;s a class three sheamp;#39;s on great medicines ACE inhibitor beta blockers sheamp;#39;s on aldosterone antagonism sheamp;#39;s on a little bit of diuretic and then on exam her blood pressure is soft but reasonable her heart rate is well controlled she doesnamp;#39;t really have evidence of elevated filling pressures and so sheamp;#39;s not acutely decompensated though she does have trace peripheral edema her ECG just show sinus rhythm with a left on the winch block and Kenny here ok and so we took her for echocardiography and if you ignore the flicker you can see she has a big sick left ventricle and in the sh