Background Suitability for the subcutaneous implantable cardioverter-defibrillator (S-ICD) depends on a pre-implant electrocardiogram (ECG) screening to ensure appropriate sensing of electrical cardiac signals. Screening is performed positioning electrodes guided by chest surface anatomical landmarks. Case summary We report a case of a patient with an initially negative conventional automatic screening for S-ICD, who underwent a modified screening guided by cardiac silhouette position, as seen under fluoroscopy, resulting in eligibility for the S-ICD. Discussion The S-ICD reduces endovascular infection risk, providing therefore a potentially safer alternative in patients with prosthetic valves. It might be reasonable to perform a pre-implant ECG screening guided by fitting the cardiac silhouette in the shock vector, as this modified screening position could increase eligibility in patients who may benefit from S-ICD therapy such as the one presented.

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