Cardiac Resynchronization Therapy Optimization in a Patient with Left Ventricular Non-Compaction Cardiomyopathy and Morbid Obesity.

Left ventricular non-compaction cardiomyopathy (LVNC) is a rare myocardial disorder associated with heart failure and arrhythmias. Cardiac resynchronisation therapy (CRT) is an established treatment in patients with electrical dyssynchrony; however, achieving optimal response remains challenging in complex clinical scenarios. We report a 51-year-old male with LVNC, severe left ventricular dysfunction, morbid obesity, and recurrent atrial and ventricular arrhythmias. Despite initial improvement following CRT-D implan-tation, the patient developed progressive heart failure and recurrent ventricular tachycardia with high atrial arrhythmia burden, resulting in ineffective biventricular pacing. Following unsuccessful device optimisation strategies, a multidisciplinary decision was made to proceed with atrioventricular node ablation. This resulted in marked clinical and echocardiographic improvement, including recovery of left ventricular ejection fraction and symptomatic status. This case highlights the importance of ensuring adequate CRT delivery and demonstrates the pivot-al role of atrioventricular node ablation in patients with refractory atrial arrhythmias and suboptimal CRT response.