Revascularization of a post ICD implanted patient - Closing the stable after the horse has bolted

Patients with significant coronary artery disease with severe left ventricular dysfunction are at risk of sudden cardiac death secondary to ventricular arrhythmias. Whether complete revascularization or implantation of implantable cardioverter-defibrillator (ICD) first is always clinical dilemma. The revascularization strategy in the presence of multivessel disease is not always without risk and not cost effective. We have discussed one such clinical scenario where patient underwent ICD implantation and later had symptoms of transient heart failure and ventricular arrhythmia secondary to ischemia. His symptoms were relieved after successful percutaneous coronary angioplasty. Revascularization is the appropriate therapy for patients with abnormal left ventricular function and residual ischemia. ICD placement makes most sense for patients who are at risk but who lack the ischemic potential that would send them to revascularization.