Implantation of the Subcutaneous Implantable Cardioverter-Defibrillator

The subcutaneous implantable cardioverter-defibrillator (S-ICD) was introduced to reduce acute transvenous leadrelated complications, such as pneumothorax, endocarditis, cardiac perforation, and lead dislodgements, as well as the complications related to chronic indwelling leads, such as lead failure, venous obstruction, and bacteremia. The standard implantation technique of the S-ICD involves 3 incisions and placement of the midaxillary pulse generator under the subcutaneous tissue. However, alternative implantation techniques have been explored including a (1) 2-incision technique, (2) submuscular implantation of the pulse generator (under the serratus anterior muscle [SAM]), and (3) subfascial implantation of the pulse generator (under the fascia overlying the serratus anterior, but above the muscle). These alternative implantation techniques for both the pulse generator and the lead have been proposed to offer both operative and cosmetic advantages. A previous report on 2-incision S-ICD implantation technique, which omits the superior parasternal incision and fixation, demonstrated short-term safety in a small cohort of S-ICD patients. However, long-term data, particularly on potential lead displacement, is lacking. Implantation of the pulse generator underneath the SAM or underneath the serratus anterior fascia has been proposed as technique that may reduce pocketrelated complications, such as erosion, while improving the esthetic appeal of the pulse generator pocket. Similarly,