A 78-year-old man with survived SCD and ischaemic cardiomyopathy underwent two-chamber ICD implantation in 1998 and several lead and device replacements via the left and right subclavian veins due to lead malfunction or device infection. Over time, RV pacing requirement increased due to complete atrio-ventricular (AV) block and ejection fraction decreased to 35%, while permanent AF emerged. In 2014, the patient was admitted to hospital with anew right ventricular (RV) lead fracture. Lead extraction and another transvenous approach were not successful due to venous occlusion. Therefore, an subcutaneous ICD (S-ICD) was combined with an abdominally located pacemaker and a bipolar epicardial lead positioned on the left ventricle (Figure). No interaction between the S-ICD and maximum output bipolar pacing (7.5 V/1.5 ms) or the pacemaker's safety programme (unipolar; 5 V/0.6 ms) occurred, while maximum output unipolar pacing evoked noise in two of three S-ICD detection vectors. Defibrillation threshold tests were performed without pacemaker interactions. Furthermore, in July 2015, it could be demonstrated in a spontaneous VF episode not being sensed by the pacemaker that bipolar pacing due to pacemaker undersensing at ongoing VF did not affect the sensing capabilities of the S-ICD in our specific case.
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