Background Techniques used to extract chronically implanted permanent pacing leads have evolved over time. These initially consisted of traction and now have evolved into counter pressure and counter traction with the assistance of specialized sheaths and locking stylets.1 The procedure has also been assisted greatly by the development of sheaths that deliver pulses of excimer laser (Spectranetics, Colorado Springs, CO) or radiofrequency current (Cook Vascular Inc., Leechburg, PA). These methods have allowed for successful lead removal but, as with any surgical procedure, the possibility of serious complications exists.2 Therefore, the decision to extract chronic leads should be made after considerable planning. Several challenges still remain, one of which is venous stenosis, which can interfere with the implantation of new leads after extraction of previously implanted leads. Due to the potential for fatal complications, surgical back up is standard, as is the collaboration with the cardiac surgeons. The recognition of venous stenosis has led to a growing need for a collaborative relationship with interventional cardiologists. Indications for implantable cardiac devices are expanding and the technology behind them is becoming more complex as cardiac resynchronization therapy gains wider acceptance.3 Our case illustrates the importance of collaborative efforts in which the combined skills of different sub-specialists are needed to overcome issues that may arise in the implantation of these devices. We present a case that demonstrates this concept: Our patient required explantation with multiple extraction methods for removal of chronic leads and balloon venoplasty to facilitate implantation of a cardiac resynchronization therapy device with defibrillation capability (CRT-D). Case Presentation In January 2003, a dual chamber pacing system was implanted in a 76-year-old male for sick sinus syndrome and severe symptomatic bradycardia. The patient s medical history included a non-ischemic dilated cardiomyopathy with an ejection fraction of 20%. Non-sustained ventricular tachycardia was documented on telemetry, and an electrophysiology study revealed no inducible arrhythmias. The dual chamber pacing system was implanted without complication and the patient was followed for the next two years in the device clinic and monitored remotely through trans-telephonic visits. During this time period, the patient was hospitalized three times for heart failure despite optimal pharmacologic therapy. Echocardiography revealed that the ejection fraction had declined to 10% and the patient was now pacemaker dependent. In January 2005, (27 months post implant) a trans-telephonic evaluation of the pacing system revealed atrial undersensing and loss of atrial capture. Pacemaker evaluation in the device clinic demonstrated low bipolar and unipolar atrial impedance values, P wave amplitude of Conclusion Our case illustrates the increasing importance of collaboration between different sub-specialists, especially during electrophysiology and implantation procedures in the current era where the indications for resynchronization therapy and ICD implantation are growing.