[Progression of heart failure during cardiac resynchronization therapy: what is the cause?]

A 74 year old patient with cardiac resynchronization therapy (CRT) since 12 months presents with cardiac decompensation and dyspnea NYHA III-IV after improvement of cardiac symptoms for 9 months. Her history is remarkable for left ventricular hypertrophy, aortic valve replacement 14 years earlier, a left ventricular ejection fraction of 35-40%, and permanent third degree AV block. The 12 lead standard ECG reveals the cause of cardiac deterioration which is confirmed by telemetry. This case demonstrates the importance of optimized programming of CRT systems which differs from conventional programming of dual-chamber devices in some aspects.