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so these are very difficult patients who have refractory heart failure they come often in the hospital with hypotension renal insufficiency and persisted edema so the first patient was a 65 66 years old patient with non ischemic cardiomyopathy with a meaty for two days of worsening this mare table and paroxysmal nocturnal dyspnea its been on your ass amide at home NATO prologue 25,000 appeal the amid blood pressure is 94 over 78 heart rate youre tachycardic with clear evidence of fluid overload and right-sided heart failure as evidenced by a jugular venous pressure of 12 centimeter mercury 3/4 plus ankle edema patient is also called in clammy and is hypoxic the kipnuk the heart rate that would reverse with a rate of 24 the initial renal function test shows that shes got what we call proven or azoty mia with a be an incredi ratios close to 20 and really the patients allegorical only urinated 200 MLS in eight hours which is not adequate what you expect from somebody who received the