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

Abstract

Background Cardiac metastases can trigger malignant ventricular arrhythmias and limit transvenous therapy with right ventricular (RV) involvement. Case Summary 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. Discussion In RV tumor involvement where transvenous leads may be unsafe, this case highlights a hybrid strategy providing defibrillation and bradycardia support. Take-Home Message S-ICD plus coronary sinus ventricular pacing is a practical option when transvenous RV lead placement is not feasible.