A 72-year-old woman was admitted to our hospital in July 2000 for shortness of breath and dizziness. The immediate history demonstrated that the patient was suffering from hypertension, type 1 diabetes, hypercholesterolaemia and atrial fibrillation. The patient also had a history of coronary artery bypass grafting for the anterior left descending and right coronary arteries, and combined mitral valvuloplasty for mitral valve regurgitation, within the context of a dilated failing heart. At the diagnosis of heart failure in January 1999, the left ventricular ejection fraction (LVEF) was 20-25% and the left ventricular end-diastolic diameter (LVEDD) was 68 mm. Follow-up in August 2000 revealed the patient to be in stable NewYork Heart Association functional class II with no other significant symptoms of heart failure. However, fitrther investigation demonstrated that her diabetes was not well controlled (HbAlc >9%). Echocardiography demonstrated an LVEF of 42%, with an LVEDD of 60 mm. The patient was admitted again in late October 2001 for symptoms of heart failure, including worsening dyspnoea (grade III) and mild episodes of dizziness, but no angina. The drug regimen at the time of admission included the following: ramipril 5 mg. day i; amlodipine 5 mg twice daily; coumadin, administered once daily, with dose titrated to achieve an International Normalized Ratio of 3.2; anaiodarone 200 mg . dayl ; digoxin 0.125 mg. dayI ; oral furosemide 8 0 m g . day l ; potassium supplement 1 g . day1; insulin; and atorvastatin 40 mg. day 1. The physical examination demonstrated mild leg oedema, no liver enlargement, an arterial blood pressure of 154/94 mmHg with a heart rate of 86 beats, min 1, and a weight of 56 kg (height 163 cm). Pulmonary auscultation confirmed bilateral r~les and no murmur. The ECG on admission demonstrated a left bundle branch block morphology, with a PR interval of 280 ms and a QRS duration of 180 ms. The chest X-ray demonstrated some pleural effusion, increased density of the pulmonary parenchyma and a cardiothoracic index greater than 50%. Creatinine phosphokinases MM and MB were normal. Serum creatinine was 160 mmol. 1-1 and potassium was 4.2 mEq. 1 1. Echocardiography demonstrated an LVEF of 26%, LVEDD 68 mm, mitral regurgitation grade 1 and left atrial diameter 50 mm. Twenty-four-hour Holter monitoring showed a sinus rhythm, with a mean heart rate of 84 beats, min1 (ranging from 74 to 126), along with pauses and bouts of nonsustained ventrieular tachycardia, as well as brief episodes of sinus dysfunction during the daytime. Thallium scintigraphy under dipyridamole showed abnormal anterior and apical perfusion, with a normalization at redistribution and a LVEF of 24%. Coronary angiography revealed significant narrowing at the site of implantation of the mammary bypass on the left main coronary artery, which was immediately and successfully treated with balloon angioplasty. Drug therapy was optimized as follows. The furosemide dose was increased to 120 mg. day1 and ramipril to 5 mg twice daily. Spironolactone was initiated at a dose of 12-5mg. day -1 and the potassium supplement was stopped. Close monitoring of serum creatinine and potassium revealed no significant changes, and spironolactone could safely be up-titrated to 25 mg. day1. At discharge, the patient was asymptomatic and free of signs of congestion. She was scheduled for ambulatory blood pressure measurement, and for a visit to the diabetes and nutrition departments for optimization of insulin and lipid-lowering therapy. She was also scheduled for readmission to the Cardiology Department after a 4-week clinical stabilization period, so that beta-blocker therapy could be initiated and the following further therapeutic options considered: implantable cardioverter-defibrillator with pacing backup (VVI-ICD); pacemaker implantation and amiodarone administration; dual chamber ICD with pacing backup (DDD-ICD) and atrial defibrillation capability; and dual chamber ICD with pacing backup (DDD-ICD), including biventricular pacing capability. After discussion, it was decided that the DDD-ICD would be the most appropriate option.