Introduction Cardiac implanted electronic devices (CIEDs) have significantly improved the survival and quality of life in heart failure patients. The role of implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy (CRT) in patients with a left ventricular assist device (LVAD) has not been well defined. CIED procedures come at a price of venous access problems, lead malfunctions and pocket complications. This requires creative approaches to tackle CIED related issues in LVAD patients. Case Report Here we describe the clinical course of a 67 year old patient with an LVAD as destination therapy. The heart failure etiology was a non-ischemic cardiomyopathy due to sarcoidosis and he was pacing dependent due to a total atrioventricular block. The patient had an ICD due to recurrent monomorphic ventricular tachycardias and a CRT indication due to previous deterioration of (right sided) heart failure in the temporary absence of biventricular pacing. He recently had a pump thrombosis which was treated medically as he was deemed too frail to undergo a pump exchange. The anticoagulation regimen consisted of a vitamin K antagonist (INR 2.5-3.0) and clopidogrel 75mg o.d.. The patient was admitted for a pulse generator exchange due to low battery voltage. We were confronted with impeding right ventricular lead failure and bilateral venous access problems due to chronic subclavian vein occlusions in a patient with 5 transvenous leads, therapeutic anticoagulation and pronounced thoracic collaterals (Fig 1). Several strategies were considered - venous angioplasty, contralateral lead tunneling and epicardial lead implantation. We sought for a creative solution to deliver biventricular fusion pacing with the existing leads from two contralateral pulse generators. This provided the least invasive solution to deliver effective CRT. Summary This case illustrates the complexity of CIED related decision making in pacing dependent LVAD patients, particularly those with an ICD and CRT indication.
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