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Figure 1 Troubleshooting algorithm for heart failure patients with worsening symptoms, progressive ventricular remodeling, or no improvement in New York Heart Association functional class despite one to six months of cardiac resynchronization therapy (CRT). AV = atrioventricular; CXR = chest X-ray; EKG = electrocardiogram; Htx = heart transplant; LV = left ventricular; LVAD = left ventricular assist device; MR = mitral regurgitation; RV = right ventricular; VV = interventricular. *Cardiac ischemia is evaluated in patients with ischemic cardiomyopathy. **Evidence of dyssynchrony includes septal to posterior wall motion delay  130 ms, intraventricular mechanical delay 40 ms, and tissue Doppler imaging 65 ms.
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