Evolution of extravascular implantable cardioverter-defibrillator therapy for ventricular arrhythmias

Implantable cardioverter-defibrillators have become an established therapy for the prevention of sudden cardiac death due to life-threatening ventricular arrhythmias in the last decades. In all those years, the use of transvenous leads has proven to be the most vulnerable part of the system. The development of the completely subcutaneous implantable cardioverter-defibrillator opened a new era of device therapy outside of the vascular system. The next step, enabling extravascular devices with the option of antitachycardia pacing, is just around the corner. This may become an important option for all patients without a bradycardia pacing indication that are in need for antitachycardia pacing because of monomorphic ventricular tachycardia. Implantable cardioverter-defibrillators have become an established therapy for the prevention of sudden cardiac death due to life-threatening ventricular arrhythmias in the last decades. In all those years, the use of transvenous leads has proven to be the most vulnerable part of the system. The development of the completely subcutaneous implantable cardioverter-defibrillator opened a new era of device therapy outside of the vascular system. The next step, enabling extravascular devices with the option of antitachycardia pacing, is just around the corner. This may become an important option for all patients without a bradycardia pacing indication that are in need for antitachycardia pacing because of monomorphic ventricular tachycardia. Key Findings▪The subcutaneous implantable cardioverter-defibrillator has become a reliable alternative to transvenous implantable cardioverter-defibrillator therapy.▪Two new developments are under investigation, opening new possibilities.▪A subcutaneous implantable cardioverter-defibrillator combined with the Empower LP provides the extravascular implantable cardioverter-defibrillator with pacing treatment options.▪The extravascular implantable cardioverter-defibrillator offers extravascular pacing in a new concept, and early studies are promising. ▪The subcutaneous implantable cardioverter-defibrillator has become a reliable alternative to transvenous implantable cardioverter-defibrillator therapy.▪Two new developments are under investigation, opening new possibilities.▪A subcutaneous implantable cardioverter-defibrillator combined with the Empower LP provides the extravascular implantable cardioverter-defibrillator with pacing treatment options.▪The extravascular implantable cardioverter-defibrillator offers extravascular pacing in a new concept, and early studies are promising.