Late Obesity-Driven Subcutaneous ICD Geometric Failure: Salvage With Sub-Serratus Generator Repositioning

S-ICD efficacy depends on extracardiac shock vector geometry. We report late obesity-associated geometric deterioration after substantial weight gain. Rising shock impedance prompted reassessment at generator replacement, revealing pocket dehiscence, adipose interposition, and generator superficialization. Because fibrosis precluded parasternal lead mobilization by simple traction, sub-serratus generator repositioning improved the PRAETORIAN score and shock impedance. Despite a subsequent rise to 130 Ω, defibrillation succeeded with a 65 J shock. S-ICD geometry should be considered dynamic, particularly after major changes in body habitus.