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A 78-year-old man presented with worsening dyspnea and edema. He had undergone coronary artery bypass grafting in 2001. At the current presentation, he had ischemic cardiomyopathy with a left ventricular (LV) ejection fraction of 0.20 and was taking home inotropic therapy. Two months previously, he had begun cardiac resynchronization therapy with use of an implanted biventricular pacemaker. Physical examination revealed elevated jugular venous pressure, bibasilar crackles, and pitting edema above both knees. An electrocardiogram (ECG) was obtained (Fig. 1).

A “De-Synching” Feeling