The extravascular ICD: Evolving paradigms in sudden death prevention

Implantable cardioverter-defibrillators (ICDs) remain the mainstay of prevention of sudden cardiac death in patients at risk of lethal ventricular arrhythmias. Current ICD systems use leads placed via transvenous, subcutaneous, or surgical epicardial approaches. The extravascular ICD (EV-ICD) is a novel device that avoids transvenous lead placement while enabling defibrillation and limited pacing including antitachycardia pacing. This review summarizes key features of the EV-ICD system and synthesizes published trial and real-world evidence. Collectively, these studies demonstrate high defibrillation success, effective antitachycardia pacing, and low complication rates. The EV-ICD is an attractive option for patients without previous sternotomy or pacing indications for bradycardia or resynchronization, particularly those at an elevated risk of transvenous lead-related complications. Further research is needed to define long-term outcomes and refine patient selection. This review offers an evidence-based evaluation of the EV-ICD's role in contemporary arrhythmia management including limitations of the device and unknowns regarding patient selection and durability.