Subcutaneous Defibrillation and Coronary Sinus Pacing After Ventricular Fibrillation With Right Ventricular...

Cardiac metastases can trigger malignant ventricular arrhythmias and limit transvenous therapy with right ventricular (RV) involvement.

A 67-year-old patient with metastatic clear-cell renal cell carcinoma and RV metastasis developed ventricular fibrillation during ambulance transport after chest pain and a hypertensive crisis. Coronary angiography revealed severe 3-vessel coronary artery disease, followed by high-risk percutaneous coronary intervention. For secondary prevention, a subcutaneous implantable cardioverter-defibrillator (S-ICD) was implanted because RV lead placement was considered unsafe. Subsequent syncope due to sinus arrest led to discontinuation of beta-blocker therapy and was followed by recurrent ventricular tachycardia treated with 6 appropriate S-ICD shocks. Implantation of a dual-chamber pacemaker with a coronary sinus ventricular lead enabled resumption of beta-blocker therapy, with no further events before discharge.

In RV tumor involvement where transvenous leads may be unsafe, this case highlights a hybrid strategy providing defibrillation and bradycardia support.

S-ICD plus coronary sinus ventricular pacing is a practical option when transvenous RV lead placement is not feasible.