Case Presentation: A 65 year old male with ischemic cardiomyopathy, EF of 25% and NYHA III symptoms despite optimal medical therapy, severe mitral regurgitation (MR) and left bundle branch block (LBBB) with QRS>150ms (figure 1) was referred for cardiac resynchronization therapy-defibrillator (CRT-D) implantation. The right atrial pacing and right ventricular defibrillator leads were successfully implanted, [...]