Nothing inside the heart – Combining epicardial pacing with the S-ICD

Introduction The implantation of implantable cardioverter-defibrillator (ICD) systems in patients with no or limited venous access is technically challenging. After disappointing experiences with epicardial ICD patches, surgical techniques focused on the implantation of subcutaneous high-voltage array electrodes or intrapericardial placement of standard transvenous ICD leads. The Boston Scientific subcutaneous ICD (Boston Scientific, Marlborough, MA) is the first completely subcutaneous ICD (S-ICD), initially approved in Europe in 2009 and market released in the United States in 2012. The S-ICD is an effective and attractive alternative to transvenous ICD systems in patients without need for antitachycardia or antibradycardia pacing. Previous trials excluded patients with existing epicardial defibrillation patches or coils, presence of epicardial pacing leads, unipolar pacemaker systems, or documented monomorphic ventricular tachycardia likely to be terminated by antitachycardia pacing. Therefore the safety and feasibility of S-ICD systems in patients with a concomitant epicardial pacing system and a class I indication for antibradycardia pacing is unknown. We report a case of a patient with an indication for both a secondary prevention ICD and permanent pacing who was high risk for recurrent bacterial seeding of a transvenous device and who underwent successful implantation of an epicardial pacemaker and a Boston Scientific S-ICD system.