Introduction
The introduction of left ventricular assist devices (LVADs) into clinical practice over the past decade has improved the care of patients with end-stage heart failure.1-3 Many patients have an existing implantable cardioverter defibrillator (ICD) at the time of LVAD implantation. LVAD Implantation can alter ICD lead parameters including RV capture threshold, RV lead impedance and R wave sensing .4,5,6 Reduced R wave sensing can result in under sensing of malignant ventricular arrythmias (VAs), and hence withhold appropriate therapy including anti-tachycardia pacing and shocks. On the other hand, oversensing of noise generated by the LVAD, can result in inappropriate ICD shocks. Furthermore, the impact of LVAD implantation on defibrillation thresholds has not been clearly established. To our knowledge, no study has systematically looked at DFTs both pre and post LVAD implantation.
Recently, there have been reports of LVAD patients presenting with multiple ineffective ICD shocks.7 Whether shock failure is the result of LVAD implantation or the patient’s severe cardiomyopathy is unknown. The workup of post LVAD patients with preexisting ICDs presenting with ineffective ICD shocks is limited. Especially the importance of an exhaustive history and physical examination in such patients is considered to be low yield. We present a case of failed ICD shocks in an LVAD patient due to the presence of a metal tongue ring. Our case highlights the importance of a dedicated history and thorough physical examination.