ArticleHeart rhythm2026
Ultrasound-guided parasternal tunneling during intermuscular subcutaneous implantable cardioverter-defibrillator implantation is associated with lower shock impedance and more favorable implant geometry.
Article in Heart rhythm, 2026. 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
backgroundSubcutaneous implantable cardioverter-defibrillator ventricular fibrillation (VF) conversion testing success is influenced by implant geometry and shock impedance. Intermuscular (IM) generator placement reduces subgenerator adiposity, but coil-sternum distance remains a determinant of elevated high-voltage impedance.
objectiveThis study aimed to evaluate whether a combined strategy incorporating fluoroscopic skin marking, IM generator placement, and intraoperative ultrasound guidance (fluoroscopy-guided skin-marked IM implantation [FUSIM]) minimizes coil-sternum distance, lowers high-voltage shock impedance, and improves radiographic parameters vs conventional approaches.
methodsWe performed a retrospective single-center cohort study of adults undergoing subcutaneous implantable cardioverter-defibrillator implantation (January 1, 2014, to December 2024). Patients were grouped by technique: fluoroscopy-guided skin-marked subcutaneous implantation (SC), fluoroscopy-guided skin-marked IM implantation (FIM), and FUSIM. The primary endpoint was high-voltage shock impedance during VF conversion testing; analyses included group comparisons and multivariable logistic regression adjusted for body mass index. Radiographic measures were assessed in a consecutive single-operator subset.
resultsAmong 265 patients (age 41.2 ± 13.8 years; 36.2% female; SC n = 87; FIM n = 118; FUSIM n = 60), VF conversion testing was attempted in 214 (80.8%). High-voltage shock impedance was available in 186 patients, and quantitative radiographic measurements were available in 225. FUSIM was associated with lower impedance (60.9 ± 11.0 Ω) than SC (75.6 ± 19.1 Ω; P < .001) and FIM (70.9 ± 17.6 Ω; P < .01). An impedance of ≥70 Ω occurred in 19.5% (FUSIM), 39.7% (FIM), and 61.1% (SC). First-shock conversion failure at 65 J occurred in 3 of 214 (1.4%), all in the SC group. IM approaches had lower PRAETORIAN scores than SC, whereas the FUSIM group showed lower coil-sternum distance (P < .01).
conclusionFUSIM strategy was associated with lower high-voltage shock impedance and more favorable radiographic parameters. A prospective multicenter evaluation is warranted to determine whether FUSIM reduces the need for routine VF conversion testing.
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