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Subcutaneous implantable cardioverter defibrillators

Jonathan Weinstock, MD, FACC, FHRS
Jeffrey Selan, MD
Arjun Majithia, MD
Section Editors
Samuel Lévy, MD
Bradley P Knight, MD, FACC
Deputy Editor
Brian C Downey, MD, FACC


Sudden cardiac death (SCD) resulting from cardiac arrhythmia is the world's leading cause of cardiovascular mortality, accounting for over 50 percent of cardiovascular deaths worldwide [1]. Implantable cardioverter defibrillators (ICDs) have been shown in numerous large clinical trials to reduce mortality from SCD in selected populations [2-6].

ICD systems consist of a pulse generator, typically placed in the pectoral region, and one or more leads which attach the pulse generator to the heart, most commonly to the endocardium via transvenous insertion (in rare circumstances epicardial leads can be used, but these require a thoracotomy and are typically only used if transvenous lead placement is no longer an option). However, conventional transvenous ICD (TV-ICD) systems come with the inherent drawbacks of transvenous leads, including:

Risks at the time of insertion – Cardiac perforation, pericardial effusion, cardiac tamponade, hemothorax, pneumothorax (see "Cardiac implantable electronic devices: Peri-procedural complications")

Delayed risks over the lifetime of the device – Intravascular lead infection, lead failure (see "Cardiac implantable electronic devices: Long-term complications")

Reports of complications at the time of TV-ICD range from 3 to 6 percent of implants. In addition, the delayed risks of transvenous leads include a risk of infection (incidence of 9 per 1000 device-years) and lead failure (ranging from 5 to 40 percent of leads at five years depending on the type of lead), both of which lead to repeat procedures and increased morbidity for patients. (See "Infections involving cardiac implantable electronic devices", section on 'Epidemiology'.)

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Literature review current through: Nov 2017. | This topic last updated: Nov 20, 2017.
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  1. Estes NA 3rd. Predicting and preventing sudden cardiac death. Circulation 2011; 124:651.
  2. Bardy GH, Lee KL, Mark DB, et al. Amiodarone or an implantable cardioverter-defibrillator for congestive heart failure. N Engl J Med 2005; 352:225.
  3. Moss AJ, Hall WJ, Cannom DS, et al. Improved survival with an implanted defibrillator in patients with coronary disease at high risk for ventricular arrhythmia. Multicenter Automatic Defibrillator Implantation Trial Investigators. N Engl J Med 1996; 335:1933.
  4. Moss AJ, Zareba W, Hall WJ, et al. Prophylactic implantation of a defibrillator in patients with myocardial infarction and reduced ejection fraction. N Engl J Med 2002; 346:877.
  5. Antiarrhythmics versus Implantable Defibrillators (AVID) Investigators. A comparison of antiarrhythmic-drug therapy with implantable defibrillators in patients resuscitated from near-fatal ventricular arrhythmias. N Engl J Med 1997; 337:1576.
  6. Moss AJ, Schuger C, Beck CA, et al. Reduction in inappropriate therapy and mortality through ICD programming. N Engl J Med 2012; 367:2275.
  7. Al-Khatib SM, Friedman P, Ellenbogen KA. Defibrillators: Selecting the Right Device for the Right Patient. Circulation 2016; 134:1390.
  8. Friedman DJ, Parzynski CS, Varosy PD, et al. Trends and In-Hospital Outcomes Associated With Adoption of the Subcutaneous Implantable Cardioverter Defibrillator in the United States. JAMA Cardiol 2016; 1:900.
  9. McLeod CJ, Boersma L, Okamura H, Friedman PA. The subcutaneous implantable cardioverter defibrillator: state-of-the-art review. Eur Heart J 2017; 38:247.
  10. Bardy GH, Smith WM, Hood MA, et al. An entirely subcutaneous implantable cardioverter-defibrillator. N Engl J Med 2010; 363:36.
  11. Anvari A, Stix G, Grabenwöger M, et al. Comparison of three cardioverter defibrillator implantation techniques: initial results with transvenous pectoral implantation. Pacing Clin Electrophysiol 1996; 19:1061.
  12. Miller MA, Palaniswamy C, Dukkipati SR, et al. Subcutaneous Implantable Cardioverter-Defibrillator Implantation Without Defibrillation Testing. J Am Coll Cardiol 2017; 69:3118.
  13. de Bie MK, Thijssen J, van Rees JB, et al. Suitability for subcutaneous defibrillator implantation: results based on data from routine clinical practice. Heart 2013; 99:1018.
  14. Huang J, Patton KK, Prutkin JM. Concomitant Use of the Subcutaneous Implantable Cardioverter Defibrillator and a Permanent Pacemaker. Pacing Clin Electrophysiol 2016; 39:1240.
  15. Aziz S, Leon AR, El-Chami MF. The subcutaneous defibrillator: a review of the literature. J Am Coll Cardiol 2014; 63:1473.
  16. Majithia A, Estes NA 3rd, Weinstock J. Advances in sudden death prevention: the emerging role of a fully subcutaneous defibrillator. Am J Med 2014; 127:188.
  17. Pettit SJ, McLean A, Colquhoun I, et al. Clinical experience of subcutaneous and transvenous implantable cardioverter defibrillators in children and teenagers. Pacing Clin Electrophysiol 2013; 36:1532.
  18. Kuschyk J, Stach K, Tülümen E, et al. Subcutaneous implantable cardioverter-defibrillator: First single-center experience with other cardiac implantable electronic devices. Heart Rhythm 2015; 12:2230.
  19. Groh CA, Sharma S, Pelchovitz DJ, et al. Use of an electrocardiographic screening tool to determine candidacy for a subcutaneous implantable cardioverter-defibrillator. Heart Rhythm 2014; 11:1361.
  20. Randles DA, Hawkins NM, Shaw M, et al. How many patients fulfil the surface electrocardiogram criteria for subcutaneous implantable cardioverter-defibrillator implantation? Europace 2014; 16:1015.
  21. Jarman JW, Lascelles K, Wong T, et al. Clinical experience of entirely subcutaneous implantable cardioverter-defibrillators in children and adults: cause for caution. Eur Heart J 2012; 33:1351.
  22. Olde Nordkamp LR, Dabiri Abkenari L, Boersma LV, et al. The entirely subcutaneous implantable cardioverter-defibrillator: initial clinical experience in a large Dutch cohort. J Am Coll Cardiol 2012; 60:1933.
  23. Köbe J, Reinke F, Meyer C, et al. Implantation and follow-up of totally subcutaneous versus conventional implantable cardioverter-defibrillators: a multicenter case-control study. Heart Rhythm 2013; 10:29.
  24. Lambiase PD, Barr C, Theuns DA, et al. Worldwide experience with a totally subcutaneous implantable defibrillator: early results from the EFFORTLESS S-ICD Registry. Eur Heart J 2014; 35:1657.
  25. Moore JP, Mondésert B, Lloyd MS, et al. Clinical Experience With the Subcutaneous Implantable Cardioverter-Defibrillator in Adults With Congenital Heart Disease. Circ Arrhythm Electrophysiol 2016; 9.
  26. Weiss R, Knight BP, Gold MR, et al. Safety and efficacy of a totally subcutaneous implantable-cardioverter defibrillator. Circulation 2013; 128:944.
  27. Jarman JW, Todd DM. United Kingdom national experience of entirely subcutaneous implantable cardioverter-defibrillator technology: important lessons to learn. Europace 2013; 15:1158.
  28. Aydin A, Hartel F, Schlüter M, et al. Shock efficacy of subcutaneous implantable cardioverter-defibrillator for prevention of sudden cardiac death: initial multicenter experience. Circ Arrhythm Electrophysiol 2012; 5:913.
  29. Dabiri Abkenari L, Theuns DA, Valk SD, et al. Clinical experience with a novel subcutaneous implantable defibrillator system in a single center. Clin Res Cardiol 2011; 100:737.
  30. Burke MC, Gold MR, Knight BP, et al. Safety and Efficacy of the Totally Subcutaneous Implantable Defibrillator: 2-Year Results From a Pooled Analysis of the IDE Study and EFFORTLESS Registry. J Am Coll Cardiol 2015; 65:1605.
  31. Chue CD, Kwok CS, Wong CW, et al. Efficacy and safety of the subcutaneous implantable cardioverter defibrillator: a systematic review. Heart 2017; 103:1315.
  32. Boersma L, Barr C, Knops R, et al. Implant and Midterm Outcomes of the Subcutaneous Implantable Cardioverter-Defibrillator Registry: The EFFORTLESS Study. J Am Coll Cardiol 2017; 70:830.
  33. Gold MR, Aasbo JD, El-Chami MF, et al. Subcutaneous implantable cardioverter-defibrillator Post-Approval Study: Clinical characteristics and perioperative results. Heart Rhythm 2017; 14:1456.
  34. Poole JE. Novel ICD therapy begets novel ICD detection: first look at the performance of the subcutaneous ICD discrimination algorithm. Heart Rhythm 2014; 11:1359.
  35. Brouwer TF, Driessen AHG, Olde Nordkamp LRA, et al.. Surgical management of implantation-related complications of the subcutaneous implantable cardioverter-defibrillator. JACC: Clinical Electrophysiology 2016; 2:89.
  36. Kooiman KM, Knops RE, Olde Nordkamp L, et al. Inappropriate subcutaneous implantable cardioverter-defibrillator shocks due to T-wave oversensing can be prevented: implications for management. Heart Rhythm 2014; 11:426.
  37. Daubert JP, Zareba W, Cannom DS, et al. Inappropriate implantable cardioverter-defibrillator shocks in MADIT II: frequency, mechanisms, predictors, and survival impact. J Am Coll Cardiol 2008; 51:1357.
  38. Sharma D, Sharma PS, Miller MA, et al. Position and sensing vector-related triple counting and inappropriate shocks in the subcutaneous implantable cardioverter-defibrillator system. Heart Rhythm 2015; 12:2458.
  39. Gold MR, Weiss R, Theuns DA, et al. Use of a discrimination algorithm to reduce inappropriate shocks with a subcutaneous implantable cardioverter-defibrillator. Heart Rhythm 2014; 11:1352.
  40. Theuns DA, Crozier IG, Barr CS, et al. Longevity of the Subcutaneous Implantable Defibrillator: Long-Term Follow-Up of the European Regulatory Trial Cohort. Circ Arrhythm Electrophysiol 2015; 8:1159.
  41. Brouwer TF, Yilmaz D, Lindeboom R, et al. Long-Term Clinical Outcomes of Subcutaneous Versus Transvenous Implantable Defibrillator Therapy. J Am Coll Cardiol 2016; 68:2047.
  42. Gold MR, Theuns DA, Knight BP, et al. Head-to-head comparison of arrhythmia discrimination performance of subcutaneous and transvenous ICD arrhythmia detection algorithms: the START study. J Cardiovasc Electrophysiol 2012; 23:359.
  43. Olde Nordkamp LR, Knops RE, Bardy GH, et al. Rationale and design of the PRAETORIAN trial: a Prospective, RAndomizEd comparison of subcuTaneOus and tRansvenous ImplANtable cardioverter-defibrillator therapy. Am Heart J 2012; 163:753.