A 64 year old woman was admitted to our unit for dyspnoea. Her chest radiograph (left panel) showed pronounced cardiomegaly. Physical examination revealed continuous machinery murmur over the infraclavicular area and her condition was confirmed to be patent ductus arteriosus (PDA) by echocardiography. Her ECG showed left bundle branch block (LBBB) with QRS duration of 180 ms. Her left ventricular ejection fraction was 26%. The pulmonary to systemic shunt ratio was 2.0 as determined by cardiac catheterisation; coronary arteries were normal. Percutaneous transcatheter closure of PDA was performed as the PDA might have contributed significantly to her heart failure. However, despite PDA closure and aggressive medical treatment, the patient remained in an inotrope dependent heart failure state. In view of LBBB and poor left ventricular function, a permanent biventricular pacemaker was implanted one week after PDA closure. Her heart failure improved following implantation of the pacemaker and she was weaned off inotropic support two days later.

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Chest radiography (middle panel) was repeated two months after discharge from hospital. The cardiothoracic ratio was reduced when compared to the pre-implantation radiograph. Her functional class was improved to New York Heart Association class II and her left ventricular ejection fraction was 33% one month after the procedures. The lateral chest radiograph (right panel) shows the positions of the atrial and two ventricular leads. The chest radiographs illustrate the dramatic reduction in cardiothoracic ratio before and after the procedures and the potential remodelling effect of biventricular pacemaker in patients with LBBB and poor left ventricular function.