An 86-year-old woman with congestive heart failure, coronary artery disease, and syncopal episodes presents for elective permanent pacemaker insertion. A recent 24 hour ambulatory electrocardiogram recording demonstrated multiple episodes of severe sinus bradycardia associated with pre-syncopal symptoms. Monitored anesthesia care is requested in light of the patient’s advanced age and associ-ated medical conditions. The infiltration of local anesthesia and isolation of the cephalic vein in the left deltopectoral groove proceeds uneventfully. During placement of the ventricular pacing lead, ventricular ectopy occurs as the lead encounters the right ventricular endocardium. Subsequently, as the lead is repositioned, ventricular tachy-cardia is induced and rapidly deteriorates into ventricular fibrillation.