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A 52 year old man with idiopathic dilated cardiomyopathy and a longstanding history of heart failure refractory to optimal medical treatment (New York Heart Association (NYHA) functional class III-IV) was referred to our cardiology department for implantation of an atrial synchronised biventricular pacemaker (cardiac resynchronisation therapy). At the time of observation, the patient complained of dyspnoea and asthenia following minimal effort. A third heart sound with mild apical systolic murmur, diffuse rales, bronchial wheezing, and modest signs of bilateral hydrothorax were detected at physical examination. An echocardiogram showed a notably dilated left ventricle (end diastolic diameter 84 mm), with global hypokinesia in the absence of pericardial effusion. The pre-procedural chest x ray is presented in panel A. After the implantation, the patient continued to assume his usual pharmacological treatment. At one month follow up, symptoms of heart failure were notably improved (from NYHA class IV to II), and physical examination was normal except for mild and inconstant right sided pleural bruits. The chest x ray showed a dramatic resolution of pulmonary congestive signs and a significant reduction in radiographic heart size (panel B), while echocardiography showed a reduction in left ventricular diameter (end diastolic diameter 79 mm).