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Methods: N/A Results: He had no symptoms of heart failure prior to his recent presentation and had been uncomplicated post-OHT with no episodes of significant rejection. Echocardiography performed 18 months prior to presentation had demonstrated normal left ventricular structure and function. The patient was admitted to hospital with decompensated heart failure. Repeat echocardiography demonstrated a dilated left ventricle with severe systolic dysfunction. Medical management for heart failure was initiated. Coronary catheterisation demonstrated only diffuse mild to moderate coronary artery disease. Endomyocardial biopsy revealed mild type 1R rejection, and the patient was treated with pulse intravenous methylprednisolone therapy. During his admission, the patient experienced worsening of his heart failure symptoms. ECG demonstrated intermittent high-grade atrioventricular block on a background of preexisting right bundle branch block and QRS duration of 143ms. Cardiac pacing was required and given his symptomatic heart failure with reduced ejection fraction and expectation of high pacing burden a decision was made to implant a CRT-pacemaker. Left axillary access was uneventful. Venography demonstrated a lateral branch and a left ventricular lead was positioned uneventfully. The remainder of the procedure was uneventful. Post-implant testing revealed excellent sensing and pacing parameters, and biventricular pacing resulted in a QRS duration of 100ms. He had resolution of his heart failure symptoms and was successfully discharged. At two-weeks follow up, sensing and pacing parameters remained excellent and the …