End stage CHF still poses one of the greatest. Therapeutic challenges in modern medicine, DDD pacing with optimal AV delay has emerged in 1990 as ingenious way of achieving synchronous LV activation. To evaluate the value of DDD pacing with optimal AVD in refractory CHF. 13 pts (10 m/ 3 F) with mean 55.5% all pts had CHF, NYHA class IV. Full clinical examination 12-lead surface ECG echo Doppler, DDD pacemaker implantation, and follow up to 6 months. Cardiac output (stroke volume showed significant increase at optimal AV delay). NYHA class was significantly improved during follow up periods after pacing. DDD pacing cannot be universally recommended for end stage CHF.