Effect of posture on the position of the subcutaneous implantable defibrillator.

BACKGROUND: The PRAETORIAN score is developed as an alternative for defibrillation testing (DFT) post subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, and assess three aspects of implant position on a bidirectional chest X-ray. The score is validated on a standard standing chest X-ray with arms elevated in the lateral view. OBJECTIVE: We aim to evaluate the effect of different anatomical positions on the PRAETORIAN score. METHODS: Thirty S-ICD patients underwent standard posterior-anterior (PA) and lateral chest X-rays, including additional lateral views in two positions: standing with arms down and supine with arms alongside the body. PRAETORIAN score and weighted kappa coefficient were calculated for each position. RESULTS: In 8 out of 30 patients the PRAETORIAN score was ≥90 in standard position. The agreement in PRAETORIAN score was substantial (κ=0.677) for the position with the arms down and fair (κ =0.399) for the supine position. In 10 patients (33%) with the arms down the PRAETORIAN score decreased, of whom 4 changed to a lower risk category. In 16 patients (53%) the PRAETORIAN score decreased in supine position, of whom 7 changed to a lower risk category of which one patient changed from high to low risk. CONCLUSION: A supine or arms-down position during chest X-rays can result in lower PRAETORIAN scores and underestimation of associated risk on DFT failure. This emphasizes the importance of correct anatomical positioning ('arms up') during chest X-rays when using the PRAETORIAN score.

Fifteen years of subcutaneous implantable cardioverter-defibrillator therapy: Where do we stand, and what will the future hold?

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a feasible alternative to the transvenous ICD in the treatment of ventricular tachyarrhythmias in patients without indications for pacing or cardiac resynchronization therapy. Since its introduction, numerous innovations have been made and clinical experience has been gained, leading to its adoption in current practice and preference in certain populations. Moreover, emerging technologies like the extravascular ICD and the combination of the S-ICD with the leadless pacemaker offer new possibilities for the future. These advancements underscore the evolving role of the S-ICD in management of ventricular tachyarrhythmias. This review outlines implantation considerations, patient selection, and troubleshooting advancements in the last 15 years and provides insights into future perspectives.