Introduction

Recent developments in the field of cardiac arrhythmology have enabled the use of new devices, such as subcutaneous implantable cardioverter-defibrillators (s-ICD), which have proved to be non-inferior to transvenous ICDs1, while potentially avoiding vascular and transvenous (TV) lead extraction-related complications. Furthermore, clinical practice has seen a comeback of older strategies, such as His-Bundle pacing (HBP), first described in 19702, which guarantees physiological stimulation of the ventricles by using the intrinsic cardiac conduction system. Recent meta-analyses have proven its safety and potential superiority to conventional right ventricular pacing (RVP)3. These novel techniques have been implemented in clinical practice alongside the use of thoroughly-corroborated electrical therapies, such as cardiac resynchronization therapy (CRT), which is a landmark therapy for heart failure (HF) with reduced left ventricular (LV) ejection fraction (LVEF)4, i.e. HFrEF, particularly in the context of HF with a high expected percentage of RVP5. Lately, His-Optimized CRT (HOT-CRT), in which HBP is sequentially followed by LV pacing (LVP), has been used in order to optimize CRT by further narrowing the paced QRS (pQRS) duration in the case of intra-ventricular conduction delay (IVCD)6.
However, the interplay between these newer and older therapeutic strategies is not always clear, especially between the use of s-ICD and pacing devices. Indeed, data from a sub-study of the Multicenter Automatic Defibrillator Implantation Trial (MADIT-II trial) suggest that only a fraction (i.e. 5.2%) of post-myocardial infarction patients with reduced LVEF develop the need for permanent pacemaker (PPM) or CRT implantation over a follow-up of 20 months, thus making them appropriate candidates for s-ICD implantation.7. However, considering the current prevalence of HFrEF8 and the widespread use of s-ICDs4, the correct pacing approach in these patients is still debated. We report the first-in-human case of biventricular PPM (CRT-P) implantation with HOT-CRT in an s-ICD patient.