June 2012
Advances in Arrhythmia and Electrophysiology
Subcutaneous Implantable Cardioverter Defibrillator
Christopher P. Rowley, MD; Michael R. Gold, MD, PhD
I mplantable cardioverter-defibrillators (ICDs) represent a
very effective therapy for primary and secondary preven-
tion of sudden cardiac death (SCD). However, implantation
of endocardial leads using a transvenous approach is associ-
ated with significant procedural and long term complications.
An entirely subcutaneous ICD (S-ICD) has been developed,
potentially eliminating many of the complications associated
with traditional transvenous ICDs. This novel approach has
been demonstrated to be a reliable and effective system for
detection and termination of ventricular arrhythmias. The
available therapeutic interventions are a result of the unique
characteristics of a high energy subcutaneous delivery sys-
tem, and therefore require appropriate patient selection to
optimize therapeutic benefit and minimize the limitations of
the first generation S-ICD. By maintaining the effectiveness
of conventional ICDs while limiting the associated compli-
cations, the S-ICD provides an alternative therapy for clini-
cians treating many patients at risk for SCD. This review
will examine the development of the subcutaneous ICD, its
advantages, limitations, and potential clinical role in the
treatment of ventricular tachyarrhythmias and prevention
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of SCD.
Background
Despite advances in cardiovascular care, SCD remains a sig-
nificant public health issue.1 A variety of nonpharmacologic
therapies for primary and secondary prevention of SCD exist,
including ICDs by endovascular lead implantation or place-
ment of epicardial defibrillation patches. Nonimplantable
strategies for SCD protection in high risk patients have also
been attempted, including a wearable defibrillator vest,2,3
as well as automated external defibrillator use at home in
selected cohorts.4 The subcutaneous ICD provides an alterna-
tive device for treatment of SCD.5
The development of an entirely subcutaneous ICD was
motivated initially by special circumstances where a tra-
ditional endovascular system was not practical. It was first
applied in the pediatric population, where congenital ana-
tomic variation often precludes safe endocardial lead place-
ment; the technique was extended to other patient populations
in whom venous access may be obstructed, may need to be
preserved, or in which chronic endovascular leads may have
a very high risk of secondary infection, as in the case of
patients with chronic indwelling catheters. These systems
From the Division of Cardiology, Medical University of South Carolina, Charleston, SC.
Correspondence to Dr Michael R. Gold, Division of Cardiology, Medical University of South Carolina, 25 Courtenay Drive, ART 7031, Charleston,
SC 29425-5920, E-mail goldmr@musc.edu.
(Circ Arrhythm Electrophysiol. 2012;5:587-593.)
© 2012 American Heart Association, Inc.
Circ Arrhythm Electrophysiol is available at http://circep.ahajournals.org
587
often required an epicardial or transvenous lead for sens-
ing, similar to the initial ICD systems developed more than
25 years ago. As a consequence of the inability or desire not
to place endovascular leads in such patients, a subcutaneous
approach emerged as case reports, primarily in the pediatric
population.6-8 However, these early hybrid systems were tra-
ditional transvenous ICDs with leads placed in the subcutane-
ous space, and only later incorporated dedicated subcutaneous
leads.9 As the feasibility of a dedicated S-ICD became appar-
ent, so did greater recognition of the increasing long term risks
of endovascular lead placement, including intravascular infec-
tion, pneumothorax, vein thrombosis, and lead fracture.10,11
Similarly, the morbidity and mortality associated with revi-
sion and extraction of chronic endocardial leads highlighted
potential long term benefits of a subcutaneous device.12 The
clinical requirement to avoid a transvenous approach, as well
as the apparent benefits, including risk avoidance, ultimately
resulted in more formal attempts to develop an entirely sub-
cutaneous ICD. As a novel approach for prevention of sudden
cardiac death, the development of an S-ICD required demon-
stration of a highly sensitive arrhythmia detection algorithm
as well as reliable defibrillation.
Arrhythmia Detection
A subcutaneous ICD presents unique challenges for identifica-
tion of life threatening ventricular tachyarrhythmias. Because
of the subcutaneous electrode location, myopotentials, noise,
and low voltage electrograms make diagnostic discriminators
fundamentally different than that of transvenous ICDs. This
raises concern of the ability to detect ventricular tachyarrhyth-
mias accurately, and in particular ventricular fibrillation (VF).
In contrast, the ultra far field signal recorded with subcutane-
ous leads more closely mimics the surface ECG, and theoreti-
cally may improve arrhythmia discrimination.
Subcutaneous versus Transvenous Arrhythmia Recognition
Testing (START) was designed as a prospective study to com-
pare arrhythmia detection with transvenous and subcutaneous
signals.13 A library of induced arrhythmias was constructed
at the time of ICD implantation, with simultaneous record-
ing of transvenous and cutaneous signals. These recordings
were then played back into the header of each device offline
to assess the comparative efficacy of the sensing algorithms
to discriminate ventricular and supraventricular tachyar-
rhythmias. The sensitivity for the detection of ventricular
DOI: 10.1161/CIRCEP.111.964676
 588  Circ Arrhythm Electrophysiol  June 2012

Table 1. Primary Results From START Comparing

Transvenous and Subcutaneous Discrimination for Induced
Ventricular and Supraventricular Arrhythmias
Specificity Results
for Transvenous* and S-ICD Systems
Single Chamber Dual Chamber S-ICD
Appropriately withheld therapy 115 100 49
Inappropriate defibrillation 35 47 1
Specificity 76.7% 68% 98%
*Pooled results from 3 manufacturers with devices programmed in single
chamber or dual chamber mode.
S-ICD indicates subcutaneous implantable cardioverter-defibrillator; START, Figure 1. Comparison of transvenous and S-ICD defibrillation
Subcutaneous versus Transvenous Arrhythmia Recognition Testing thresholds. Paired defibrillation threshold data in 49 consecu-
Data from Gold MR, Theuns DA, Knight BP, Sturdivant JL, Sanghera R, tive patients demonstrates the higher energy requirements for
Ellenbogen KA, Wood MA, Burke MC. Head-to-head comparison of arrhythmia subcutaneous defibrillation. The mean defibrillation thresholds
for transvenous (*) and subcutaneous configurations (†) were
discrimination performance of subcutaneous and transvenous ICD arrhythmia
11.1 J and 36.6 J, respectively. Adapted from N Engl J Med
detection algorithms: the START study. J Cardiovasc Electrophysiol. Article first 2010;363:36-44, with permission.
published online: 28 Oct 2011.

used in this study were placed to mimic the location of the

tachyarrhythmias was uniformly excellent. However, the
present commercially developed S-ICD system. The larger
S-ICD showed the best specificity for discrimination of supra-
energy requirement for subcutaneous defibrillation places
ventricular arrhythmias (Table 1). Moreover, dual chamber
technological constraints on the S-ICD system, including
algorithms did not improve transvenous arrhythmia detection.
larger pulse generator size, shorter battery life, and limited
Although START showed that the S-ICD very accurately
provision of nonshock therapies such as temporary pacing.
detects and discriminates ventricular or supraventricular
Therefore, any subcutaneous ICD system must optimize
tachyarrhythmias at implantation, other causes of inappro-
energy output by using a lead configuration that promotes
priate detection are possible in ambulatory or chronically
efficient and effective defibrillation that is technologically
implanted patients. In this regard, inappropriate shocks due
and biologically achievable.
to myopotential sensing, double counting, and suboptimal
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The efficiency of subcutaneous defibrillation has been

sensing vector selection have been observed in studies of
shown by finite element modeling to be improved by longer
implanted S-ICD systems.14 These often can be mitigated
electrode coil length as well as using configurations that place
by optimal programming and vector selection to improve
the shock vector close to the center of ventricular myocar-
electrograms and limit artifact. The current S-ICD sys-
dial mass.15 As such, other shock vectors have been assessed
tem, for example, allows for several vectors to be used for
for defibrillation using various combinations of electrode
arrhythmia detection, including distal to proximal electrode
lead length, lead placement, and pulse generator location.
as well as either electrode or pulse generator. The system
Grace et al16 evaluated an anterolateral shock vector using
automatically selects the best vector that avoids noise, QRS
an 8 cm left parasternal electrode and a left lateral thoracic
double counting, and T-wave oversensing. Diagnostic algo-
can, and reported a defibrillation threshold (DFT) of 36.6 J,
rithms then are applied for arrhythmia detection, including
with patient not defibrillated up to 83 J. Burke et al17 evalu-
an optional discrimination zone to distinguish supraven-
ated an anterior-anterior vector by placing an anterior can in
tricular tachycardia from ventricular tachycardia. When
a clavicular pocket and an anterior cutaneous defibrillation
this approach was applied to 137 induced episodes of VF
patch electrode. In 7 of 9 patients (78%), successful defibril-
in 53 patients, all episodes were appropriately detected.
lation was achieved using 50 J, whereas 2 patients required
Additionally, there were no inappropriate shocks for atrial
100 J to terminate VF. Lieberman et al18 evaluated an anterior-
fibrillation, sinus tachycardia, or supraventricular tachycar-
posterior shock vector placing the can in a low medial pecto-
dia in 10 months of follow-up.5 Despite these encouraging
ral position and a 25 cm coil electrode tunneled posteriorly
results, there are no prospective comparisons of arrhythmia
between the 6th and 10th intercostal spaces. Using this shock
detection between subcutaneous and transvenous ICDs with
configuration, 26 out of 32 patients (81%) were defibrillated
long term follow-up.
using 35 J or less. Of those, 18 patients were defibrillated
with 17 J or less.
Arrhythmia Termination These pivotal studies demonstrated the ability to terminate
Because of the subcutaneous placement of the shocking ventricular arrhythmias using a variety of shock vectors and
electrode, the energy required for successful defibrilla- with variable energy requirements, thus leading to develop-
tion is higher than for transvenous ICDs (Figure 1). In a ment of the fully implantable S-ICD. Prior to permanent
comparative study performed at the time of ICD implanta- implantation and long term testing of the present S-ICD
tion, the average defibrillation threshold for transvenous system, 4 lead configurations were tested using specific ana-
and S-ICDs was 11.1±8.5 J and 36.6±19.8 J, respectively tomic landmarks. The configuration with the lowest mean
(P<0.001), using a binary search algorithm.5 The electrodes defibrillation threshold at 32.5±17 J used a left lateral pulse
 Rowley and Gold   Subcutaneous ICD   589

generator and an 8 cm coil electrode positioned along the left

parasternal margin.5 Other configurations tested (defibrilla-
tion threshold) included a left pectoral pulse generator with
a left parasternal 4 cm coil electrode at the inferior sternum
(40.4±13.7 J), a left pectoral pulse generator with an 8 cm
coil electrode curving from the left inferior parasternal line
across to the inferior margin of the left sixth rib (40.1±14.9 J),
and a left lateral pulse generator with a left parasternal 5 cm
oval disk (34.3±12.1 J).
Following selection of the optimal S-ICD configuration,
the system then was evaluated in 59 patients who each had
2 episodes of VF induced at the time of implantation. Of
these, 58 patients (98%) were successfully converted with 65
J on both occasions.5 The 59th patient was defibrillated suc-
cessfully during the first but not second attempt. Following
permanent implantation of the S-ICD, the device was set to
deliver only 80 J shocks to ensure an adequate safety mar-
gin. During a mean 10 months of follow-up there were 12
episodes of spontaneous ventricular tachycardia occurring in
3 patients that were treated successfully. The successful ter- Figure 2. Anatomic locations of S-ICD components with sensing
mination of VF and sustained ventricular tachycardia (VT) vectors. The sensing vector can be selected from the proximal
electrode B-CAN (primary), the distal electrode A-CAN (second-
also had been balanced with appropriately withheld thera- ary), or the distal to proximal electrode A-B (alternate).
pies in patients with detected but nonsustained episodes.14 In
a single center experience reporting on 31 S-ICD implants,
52 sustained episodes of VF induced at the time of implant is programmed “on”, tachyarrhythmias occurring between
were detected appropriately and treated in all episodes.14 170 and 240 bpm initiate arrhythmia discrimination analy-
Four patients had spontaneous ventricular tachyarrhyth- sis. This step wise approach to arrhythmia discrimination
mias in an average of 286 days of follow-up, which were all incorporates template matching that is conceptually similar
treated successfully. to that found in transvenous devices. However, transvenous
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ICDs typically use a limited number of analysis points for

The Subcutaneous Implantable
Cardioverter-Defibrillator
An entirely subcutaneous ICD (Cameron Health
Incorporated) has been developed and is the first subcutane-
ous ICD permanently implanted with long term follow-up.5
As noted previously, acute studies at the time of transvenous
ICD implantation demonstrated effective rhythm detection
and defibrillation. The S-ICD can be implanted by use of
anatomic landmarks, obviating the need for fluoroscopy,
thereby reducing radiation exposure for both the patient and
physician. With this system the pulse generator is placed in
a left lateral position between the midaxillary and the ante-
rior axillary lines. The pulse generator is connected to a 3
mm tripolar parasternal electrode (polycarbonate urethane)
that is tunneled 1 to 2 cm to the left of and parallel with the
sternal midline via 2 parasternal incisions. The electrode has
a distal sensing electrode next to the manubriosternal junc-
tion and a proximal sensing electrode next to the xiphoid
process, with an 8 cm shocking coil separating the 2 sensing
electrodes.
Rhythm detection is performed using 1 of the 3 vectors
formed between available combinations of either sensing
electrode and pulse generator (proximal-to-canister (CAN),
distal-to-CAN, and distal to proximal; Figure 2). Three
different algorithms are applied to each cardiac signal to
prevent double counting and T-wave oversensing.13 After
the optimal sensing vector is automatically selected by the
S-ICD, the heart rate then is calculated as the average of
the last 4 intervals. When the optional discrimination zone
morphological comparison, whereas the S-ICD evaluates up
to 41 points of the ventricular complex in an effort to improve
signal resolution. Rhythm analysis is performed using an 18
of 24 beats duration criteria.13
During device implantation arrhythmia termination is tested
using 65 J shocks to establish an adequate safety margin.
However, following implantation the device output is non-
programmable and will only deliver 80 J shocks. The average
capacitor charge time is 14±2 seconds, which is significantly
longer than that of transvenous ICDs. After capacitor charg-
ing and prior to shock delivery, the arrhythmia is reconfirmed
to ensure the presence of a sustained ventricular arrhythmia.
If initial therapy is unsuccessful the device can reverse shock
polarity automatically. Postshock asystole occurring for more
than 3.5 seconds triggers demand pacing at 50 bpm using a
200 mA biphasic transthoracic pulse, and is available for 30
seconds. Up to 24 treated events can be stored with 120 sec-
onds of recorded electrogram per event from arrhythmia onset
to termination.
Complications of S-ICD implantation include lead migra-
tion, pocket infection, and parasternal lead dislodgement in
the absence of adequate anchoring at the distal electrode.5,14
Long term data regarding lead durability is not yet available.
Inappropriate shock therapy has been described resulting
from myopotentials, oversensing, and double counting. In
1 report these issues were primarily resolved with software
updates and alternative vector selection, though 1 patient
required lead repositioning.14
 590  Circ Arrhythm Electrophysiol  June 2012
Table 2. Subcutaneous Implantable Cardioverter-Defibrillator
Patient Selection
S-ICD Candidate Selection
Favorable Factors Relative Contraindications
Young and active Recurrent monomorphic VT
CHD that limits lead placement Bradycardia requiring pacing
Indwelling catheters Indication for CRT
Immunocompromised High risk for VT (e.g. sarcoidosis, ARVD)
Inherited channelopathies Preference for remote monitoring
S-ICD indicates subcutaneous implantable cardioverter–defibrillator;
VT, ventricular tachycardia; CHD, congenital heart disease; CRT, cardiac
resynchronization therapy; ARVD, arrhythmogenic right ventricular dysplasia.
Subcutaneous Implantable Cardioverter-
Defibrillator Advantages
The subcutaneous ICD was initially developed for
patients who were not candidates for transvenous ICDs,
such as those with some congenital heart abnormalities or
no venous access. However, there are several advantages
of the subcutaneous approach that may make it a preferred
approach for prevention of SCD rather than simply an alter-
native to transvenous ICDs in select patient populations
(Table 2).
Without requiring venous access there is no risk of vascular
injury and presumably a very low risk of systemic infection.
Such an intravascular sparing procedure can be important
when infectious risks are high or venous access must be pre-
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served for other needs, such as hemodialysis. Patients with
artificial valves or those receiving chronic immunosuppres-
sion may be excellent candidates for a subcutaneous ICD, as
the consequences of systemic infection are more serious in
these populations.
In addition to a simplified implantation procedure, the
subcutaneous approach also avoids the risks associated with
endovascular lead extraction. With the failure rate of trans-
venous leads variably reported as 28% to 40% at 8 years,12 a
subcutaneous approach could substantially reduce risks asso-
ciated with lead extraction and is particularly suited to young
patients with a long life expectancy and higher lead failure
rates due to active lifestyles. This includes patients with
several genetic disorders where the risk of bradycardia and
monomorphic VT is low, such as Brugada syndrome, long QT
syndrome, and hypertrophic cardiomyopathy. Additionally,
the S-ICD may prove beneficial in patients anticipating car-
diac transplantation by avoiding significant endovascular
fibrosis that may complicate surgical lead extraction at the
time of transplant.
Paradoxically, the S-ICD may have some cosmetic advan-
tages despite its larger size. The anatomic location in the lat-
eral axilla is preferred anecdotally, particularly by women, to
the prepectoral location of ICDs in some patients.
There may also be an inherent benefit to subcutaneous
versus transvenous defibrillation. While S-ICDs have higher
energy requirements for effective defibrillation, the energy
is distributed more evenly throughout the myocardium.19 In
fact, with approximately 10% of delivered energy reach-
ing the heart, cardiac myocytes are exposed to a relatively
low voltage gradient.20 By contrast, endocardial defibrilla-
tion results in uneven energy delivery, with potentially high
voltage gradients that can damage myocytes through the
process of electroporation, leading to transient myocardial
stunning.19,21 In animal models using serum troponin levels
as a measure of myocardial injury following defibrillation,
endocardial defibrillation resulted in significant troponin
release at 35 J, while subcutaneous defibrillation with 80
J did not cause troponin release.22,23 Several studies have
identified a relationship between ICD shocks and mortal-
ity.24-27 Though it is unknown whether ICD shocks are a risk
factor for mortality or a risk marker for disease severity,
a defibrillation technique that minimizes myocyte damage
theoretically may mitigate any potential hazard. This may
be of particular importance in patients with already reduced
left ventricular systolic function whose limited reserve may
not withstand endocardial defibrillation associated myocar-
dial injury.
Subcutaneous Implantable
Cardioverter-Defibrillator Limitations
In its current iteration there are several limitations of
S-ICDs that may make the approach unsuitable for certain
patient populations. The device is designed to deliver high
energy shocks for termination of lethal arrhythmias but, with
the exception of 30 s of backup pacing for postshock asys-
tole, does not have backup pacing ability for bradyarrhyth-
mias. Even in the absence of a clear bradycardia indication
for pacing, a small percentage of patients who require ICDs
go on to require pacing at a later time.28 Additionally, biven-
tricular pacing in addition to an ICD (CRT-D) has been dem-
onstrated to reduce heart failure hospitalizations and mortality
in patients with heart failure, QRS prolongation, and reduced
left ventricular systolic function.29-31 Cardiac resynchroniza-
tion therapy remains an important therapeutic intervention not
available with an S-ICD. In fact, patients with any pacing indi-
cation are best served with a transvenous ICD.
Whereas the S-ICD is not intended for treatment of bra-
dyarrhythmias, the treatment available for ventricular tach-
yarrhythmias is limited to high energy shocks without the
ability to first attempt pace termination. Antitachycardia
pacing (ATP) has been shown to be a safe and effective
therapy for initial treatment of spontaneous fast VT, thereby
limiting the number of shocks delivered.32 Though the asso-
ciation of both appropriate and inappropriate shocks with
mortality is not fully understood, optimal ICD program-
ming frequently incorporates initial attempts at ATP in an
effort to avoid high energy shocks. This programming is
supported by data suggesting that the potentially deleteri-
ous effect of ICD shocks can be mitigated in part by use of
ATP.33 Therefore, the S-ICD should be avoided in patients
with known monomorphic VT and potentially those at
high risk for VT, such as sarcoidosis or right ventricular
dysplasia.
In general, the clinical results with the use of dual cham-
ber ICDs have been disappointing. Dual chamber pacing has
been associated with worse clinical outcomes compared with
backup single chamber pacing.28,34 Moreover, the addition of
an atrial lead has not improved arrhythmia discrimination.26,35,36

However, recent data suggest that monitoring of atrial tachyar-
rhythmias has important prognostic significance,37-39 though
such information is not available with the S-ICD. In patients
requiring a primary or secondary prevention device who also
have atrial arrhythmias, the ability to monitor atrial activ-
ity provides the opportunity to manage electrophysiological
comorbidities more comprehensively. Whether judicious use
of atrial detection offsets any deleterious effects of an addi-
tional lead and the often observed increased ventricular pacing
remains to be determined.
Most transvenous ICDs are also capable of being monitored
remotely, which simplifies follow-up, reduces office visits,
and is associated with better patient outcomes. At present, the
S-ICD has no remote monitoring capabilities.
Because of the higher energy requirements for subcuta-
neous defibrillation the pulse generator is larger compared
with contemporary transvenous ICDs. Despite its larger
size the anticipated battery life of the S-ICD is approxi-
mately 5 years, which is somewhat shorter than transvenous
defibrillators, and may impact the cost effectiveness of this
device.
In the absence of a previously standardized S-ICD system,
long term safety and efficacy data are not currently available.
While several European centers have presented their follow-
up data for the S-ICD, the research and clinical cardiology
community have significantly greater data and experience
with transvenous systems. An improved long term under-
standing of battery life, lead durability, appropriate and inap-
propriate shocks, effective shocks, requirement for addition of
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a transvenous pacing lead, pain associated with subcutaneous
defibrillation, and patient preference will help tailor patient
selection.
Discussion
The development of an entirely subcutaneous ICD repre-
sents one of the most significant changes in implantable
ICD technology in the last 10 years and may change the
approach to many subjects at increased risk of SCD. There
are several important implications of the subcutaneous
approach. First, it provides a clinically proven ICD system
for patients who are either not eligible for a traditional endo-
vascular ICD or are at high risk for endovascular lead place-
ment. Such patients may now be able to receive clinically
proven protection from SCD without the risks associated
with endovascular leads. Second, by standardizing a sub-
cutaneous system, important clinical outcomes can be com-
pared more directly with other available traditional ICDs,
thereby further tailoring each system to patient populations
that are likely to benefit most from each therapy. Third,
the improved specificity of arrhythmia discrimination pro-
vides additional insight into successful sensing vectors and
arrhythmia algorithms. Finally, ICD technology can be dis-
seminated more widely as fluoroscopy, and training in elec-
trophysiology is not needed for the implant procedure. The
need for defibrillation efficacy testing will be determined by
ongoing studies, but the potential exists eventually for this
system to be implantable in any facility with sterile proce-
dure rooms and a physician with basic surgical skills. This
would widely expand implant centers, not only in North
Rowley and Gold   Subcutaneous ICD   591
America and Europe, but even more so in other geographies
with fewer electrophysiologists.
Interestingly, the S-ICD does not separately evaluate atrial
activity, though it had the highest specificity for ventricular
arrhythmias when compared with both single chamber and
dual chamber transvenous systems in START. There are
several possible explanations for this finding, including the
earlier use of morphology discriminators in the S-ICD com-
pared with late stage morphology discriminators used by
most transvenous ICD systems, the number of data points
obtained for morphology template comparison, or the ultra
far field electrograms that are used for interpretation. The
improved specificity may lead to further analysis of current
ICDs and ultimately result in improved arrhythmia discrimi-
nation. Long term data are still needed to insure that this
improved detection with induced rhythms translates into better
discrimination of spontaneous arrhythmias as well as extrac-
ardiac signals, both biological (eg, pectoral and diaphragmatic
myopotentials) and extrinsic noise.
Although the S-ICD has been demonstrated to identify
and treat ventricular arrhythmias accurately and effectively,
there are several technical limitations that will limit its more
widespread use. The absence of any pacing ability, other than
postshock, eliminates several important clinical therapies,
including back up pacing for bradyarrhythmias, resynchroni-
zation therapy for heart failure, and antitachycardia pacing.
Whereas patients who develop a pacing indication after place-
ment of an S-ICD can still have endovascular pacing leads
placed, this eliminates or significantly reduces the more favor-
able risk profile of the S-ICD and is a very costly strategy.
Furthermore, additional diagnostic information and the sim-
plicity of follow-up associated with remote monitoring capa-
bilities is a technical limitation of the S-ICD at this time.
There are many patients in whom the limitations of the
S-ICD appear less than the long term complications and risks
of transvenous devices. Therefore, the S-ICD may be a pre-
ferred approach for primary prevention in young patients,
dialysis patients, those with previous infected systems, and
those with inherited diseases such as Brugada syndrome, long
QT syndrome, or idiopathic VF where the risk of VT is very
low. The role of subcutaneous ICDs in other populations will
evolve over time as long term data become available compar-
ing outcomes with transvenous ICDs.
Clearly some patients will not be candidates for an S-ICD
and others will be excellent candidates; the majority of
patients requiring an ICD, however, will likely be candidates
for either a subcutaneous or transvenous device. The largest
determinant of device selection is likely to be clinician prefer-
ence and experience. With relatively few clinicians currently
trained in the S-ICD implant technique, it is likely that the
transvenous approach will continue to be preferred, especially
as long term efficacy and safety data continue to be acquired.
However, with increased physician training in implant tech-
nique as well as patient selection, the S-ICD is likely to gain
in popularity.
Conclusion
The subcutaneous approach to ICD implantation was devel-
oped initially for patients in whom a transvenous approach
 592  Circ Arrhythm Electrophysiol  June 2012
was not feasible. Having demonstrated effective arrhythmia
detection, discrimination, and termination, the first purpose
built entirely subcutaneous ICD was developed. With appro-
priate patient selection, the S-ICD is emerging as an effective
alternative to transvenous systems for primary and secondary
prevention of sudden cardiac death.
Disclosures
Dr Gold is a consultant, is involved in clinical trials, and receives
honoraria from Boston Scientific, Cameron Health, Medtronic, St.
Jude, and Sorin.
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KEY WORDS: defibrillation ◼ electrophysiology ◼ sudden death
◼ tachyarrhythmias