Left ventricular assist devices (LVADs) provide circulatory support to patients with severe left ventricular systolic dysfunction. Many such patients have a pre-existing implantable cardioverter defibrillator at the time of their LVAD surgery. LVAD implantation can alter ICD lead parameters including R wave sensing, RV capture threshold, and impedance. These changes can in turn affect the ability of the ICD to successfully treat malignant ventricular arrythmias. In most patients who present with ineffective ICD shocks, the failed shock is assumed to be secondary to the patient’s severe cardiomyopathy. Especially the role of physical examination in such patients is often minimized. In our patient a thorough history and history guided physical examination, led us to the root cause of his failed ICD shocks. Our patient was noted to have a metal tongue ring, which was the likely cause of his ineffective ICD shocks. Our case highlights the importance of a comprehensive history and physical examination.

Background: Recently there have been reports of LVAD patients presenting with multiple ineffective ICD shocks. In such patients, azygous vein coil placement by providing an alternative anterior-posterior trajectory of the electrical shock vector can enable successful defibrillation. Objective: This review provides a hands-on approach to azygous vein coil implantation. Additionally, we compare our tools and technique to those that have been previously described by other operators. Methods: From 2018 to 2021, 8 patients were identified who underwent azygous vein coil implantation at MedStar Washington hospital center using specific tools and technique. Demographic and procedural data were obtained by retrospective review of patient charts, procedure logs, fluoroscopy, and venography performed during device implantation. Results: The indication for azygous vein coil implantation was ineffective ICD shocks in 7 patients. The presenting rhythm was VF in 6/8 (75%) cases and sustained VT in 2/8 (25%) cases. Using the approach described, we were able to successfully implant an azygous vein coil in all 8 (100%) patients. There were no procedure-related complications. Post implantation, defibrillation testing (DFT) was successfully performed in 6/8 (75%) patients. One patient failed DFT testing despite the placement of an azygous vein coil. In another patient, DFT testing was not performed because the patient was in atrial fibrillation and was not systemically anticoagulated. Conclusion: Placement of an azygous vein coil in LVAD patients with failed ICD shocks using the tools and technique described in this review is safe and highly efficacious (successful in 100% cases).

Sustained ventricular tachycardia and ventricular fibrillation (VF) are life-threatening arrhythmias which remain highly prevalent in patients with advanced heart failure. These ventricular arrhythmias may impair the support provided by CF-LVADs and lead to frequent hospitalizations, antiarrhythmic medication use, external defibrillations, and need for heart transplantation. We report a case in which a patient with a CF-LVAD and an ICD at end-of-life (EOL) presented with asymptomatic low-flow alarms and was found to have VF of unknown duration. Unique in our case was the presence of organized contractility and rhythmic opening of the mitral valve on echocardiogram despite VF on ECG.