Assessment of the Extravascular Implantable Defibrillator: Feasibility of Substernal Ventricular Pacing

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Conventional transvenous implantable cardioverter‐defibrillators (ICD) are most commonly used in patients at risk for sudden cardiac death, but lead‐related complications are an important drawback.1 The subcutaneous ICD (S‐ICD) is designed to overcome lead‐related complications by using an extra‐thoracic parasternal sensing and defibrillation lead, which results in a higher defibrillation threshold and larger pulse generator.2 Also, the S‐ICD lacks antitachycardia and chronic bradycardia pacing capabilities. Therefore, alternative configurations are desirable. An extravascular ICD configuration, with a substernal lead between the sternum and the heart and a left lateral pulse generator, potentially combines the advantages of the S‐ICD with lower defibrillation thresholds, a smaller pulse generator size, and the ability to pace the heart.3 The objective of this study was to assess the feasibility of ventricular pacing from the substernal space, and to determine optimal pace configuration and associated pacing thresholds.
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