CASE PRESENTATION: A 44 year old male with history of dilated cardiomyopathy s/p AICD presented to our ER with complaints of SOB, dry cough, and leg edema. Patient reportedly stopped taking his Lasix two weeks ago. Exam was significant for elevated JVD, mild crackles and pedal edema. Labs showed elevated troponin (0.41 ng/ml) and BNP (1771 pg/ml). Echocardiogram revealed severely decreased LV systolic function (EF <10%) with severely dilated LV cavity, severe diastolic dysfunction, prominent LV trabeculations, and deep inter-trabecular recesses communicating with the LV cavity, consistent with LVNCC (Fig. 1). Patient was initiated on diuretics and an aldosterone antagonist, added to his regimen of beta blocker and ACE inhibitor, started on IV heparin, and subsequently bridged to Coumadin for anti-coagulation for low EF. He was discharged in stable condition to follow up with advanced heart failure for Cardiac Transplant and LVAD evaluation.