ArticleEuropean heart journal. Case reports2025
Utility and feasibility of intra-pocket mapping technique for optimal subcutaneous implantable cardioverter defibrillator implantation positioning for R-wave detection: a case series.
Article in European heart journal. Case reports, 2025. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: A subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to a conventional transvenous implantable cardioverter defibrillator for preventing sudden cardiac death. Although posterior chest S-ICD implantation has been recommended for better defibrillation outcomes, little is known about the optimal S-ICD positioning for R-wave detection. Herein, we report two cases of S-ICD recipients in whom antero-inferior chest positioning improved R-wave detection after posterior chest positioning failed. Case summary: Two patients experienced intraoperative S-ICD sensing test failures despite passing the preoperative screening. The first case was a 66-year-old man with arrhythmogenic right ventricular cardiomyopathy and superior vena cava syndrome due to transvenous leads. After lead extraction and initial S-ICD placement in the posterior of the mid-chest line, sensing tests failed in all vectors. We performed intra-pocket mapping and repositioning to the antero-inferior chest position, which enabled R-wave detection and a successful defibrillation threshold test. The second case involved a 34-year-old man with short QT syndrome, whose intraoperative sensing tests also failed in all vectors. Antero-inferior repositioning of the S-ICD generator achieved acceptable R-wave detection without T-wave over-sensing and defibrillation threshold test failure. Discussion: These cases highlight the utility of intra-pocket mapping to optimize S-ICD positioning for R-wave detection in patients with challenging electrocardiogram characteristics. Posterior chest positioning may not be optimal for R-wave detection, particularly in patients with low R-wave and/or high T-wave amplitudes. Repositioning the device closer to the left ventricular apex improved sensing test results, supporting antero-inferior chest placement as a potential solution when posterior chest placement fails.
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