A 78-year old male patient with a left-sided superior vena cava presented with systemic device infection and atrial fibrillation. Transvenous lead extraction was successfully performed. Due to a previously difficult endovascular left-ventricular (LV) lead implantation and pacemaker dependency, an epicardial LV-lead was implanted via minimally-invasive left-lateral thoracotomy. Simultaneously, due to AF, left-atrial appendage closure using an epicardial clip was performed through the same access. The patient was discharged with a wearable defibrillator and scheduled for a CRT-D upgrade eight weeks later. An implantation of new transvenous RV- and RA lead was performed and the existing left-ventricular epicardial lead was used.