A 71-year-old man with sinus node disease initially had a dual-chamber pacemaker implanted in 2007. Six months later, ventricular tachycardia was detected on interrogation of his pacemaker and a transthoracic echocardiogram confirmed moderate global left ventricular (LV) dysfunction. Following exclusion of coronary ischaemia, he underwent an upgrade to an implantable cardioverter defibrillator (ICD). In 2011, he underwent an end-of-life generator replacement; he was in complete heart block at that time. Both leads demonstrated satisfactory parameters. In 2012, he had a ventricular tachycardia storm resulting in numerous deliveries of therapy. Owing to persistent New York Heart Association-III symptoms with moderately impaired LV function and pacing-induced left bundle branch block, a cardiac resynchronisation defibrillator was indicated. At implant, an ipsilateral venogram revealed subclavian stenosis; however, a coronary sinus lead was able to be advanced to provide LV pacing. On disconnecting the DF1 right ventricular (RV) shock lead from the device, an insulation breach close to the RV distal coil pin was noted. Owing to subclavian stenosis, a new DF4 lead could not be advanced, and lead extraction was deemed high risk. Thus, the pace/sense IS-1 pin, right atrial, and LV leads were attached to a cardiac resynchronisation-P, all demonstrating satisfactory parameters. The following day, he underwent screening and subsequent implantation of a subcutaneous defibrillator. At 1-year follow-up, both device parameters were satisfactory, he was free of heart failure signs and symptoms, without any arrhythmias detected or therapies delivered.
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