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.
