Chair Suneet Mittal (New York, US) led this session on extravascular implantable cardioverter-defibrillator (ICD) technology, featuring case operator Devi Nair (Jonesboro, US) and panellist Anish Amin (Columbus, US). Dr Amin outlined the advantages of extravascular ICDs, which provide high-voltage therapy for sudden cardiac death prevention while also offering pacing without transvenous leads. The panel reviewed pivotal trial data, showing a 98.7% ventricular fibrillation (VF) conversion success rate and 92.6% freedom from major complications. However, inappropriate shock rates of 11.7%, mainly due to P-wave over sensing, were noted, with mitigation strategies including procedural modifications and enhanced algorithms. The importance of pre-procedure imaging for optimal lead placement was also highlighted.

Dr Nair presented a case of a 52-year-old female with prior lead extraction and SVC syndrome, requiring an extravascular ICD. The implantation involved substernal lead placement via blunt dissection and fluoroscopic guidance. The faculty discussed optimal lead positioning, sensing assessments, and strategies to avoid atrial oversensing. The case also demonstrated successful 30J defibrillation testing. The session concluded with a discussion on patient selection, comparing extravascular and subcutaneous ICDs in hypertrophic cardiomyopathy cases.