Shoulder joint dislocation as an unusual complication of defibrillation threshold testing following subcutaneous implantable cardioverter-defibrillator implantation

A 53-year-old man underwent implantation of a totally subcutaneous ICD (S-ICD; Boston Scientific). He was positioned supine, with the left arm abducted, externally rotated (i.e. palm up) and strapped to the arm extender. The generator was placed in the left mid-axillary line along the 5th-6th intercostal spaces and the defibrillation coil was tunneled anterior to the sternum. Defibrillation threshold (DFT) testing with 65 Jcaused a forceful pectoralis twitch. The patient woke up with a painful anteriorly dislocated left shoulder. Glenohumeral dislocation due to DFT testing has not been previously reported. It is likely that this complication is specific to the S-ICD implantation, and is related to positioning with the arm abducted, externally rotated, and immobilized, and use of greater defibrillation energy with current pathway through the bulk of the pectoralis muscle.Precautions may include extending the arm palm down, strapping the arm loosely, and adduction of the arm for DFT testing.