CASE PRESENTATION: This is a 64 year woman with past medical history of diastolic heart failure who was initially admitted to the intensive care unit (ICU) for hypoxemia, acute hypercapnia, and chest congestion with bilevel positive airway pressure (BiPAP) support. While patient was treated in the ICU and medical wards, patient still had complaints of dyspnea at rest, and despite attempts to optimize her BiPAP setting, remained dyspneic at rest, hypoxic with resting tachycardia, and continuously BiPAP dependent. She was initially treated diuretics and sildenafil with no response. Thereafter, patient was started on 0.01 mcg/kg/ml Nesiritide for 1 week as a continuous infusion. With Nesiritide treatments, patient was able to wean off BiPAP, became less dyspneic at rest, and had a dramatic improvement in arterial blood gases (ABG). Patient was followed outpatient at the heart failure center for biweekly treatments which consisted of IV nesiritide. Her initial ECHO demonstrated left ventricular hypertrophy with diastolic dysfunction, severe right ventricular dilatation, right ventricular hypokinesis, and PH estimated at 69.2 mmHg. Her follow up ECHO at 8 months revealed decrease in left ventricular enlargement, normalization of right ventricular size and function with no evidence of PH.