Transvenous or Subcutaneous ICD — Similar but Different

This editorial analyzes the PRAETORIAN trial, a noninferiority study comparing transvenous implantable cardioverter-defibrillators (ICDs) with subcutaneous ICDs in patients eligible for either device. Both systems showed similar efficacy in preventing arrhythmic sudden death, with comparable rates of the composite endpoint device-related complications and inappropriate shocks. However, transvenous ICDs had more lead-related issues, while subcutaneous ICDs experienced more inappropriate shocks. The authors discuss limitations of the trial, including industry funding, short follow-up, and exclusion of patients needing pacing. They highlight opportunities for future improvements in device programming and sensing algorithms and consider broader factors such as device size, longevity, pacing capabilities, and cost-effectiveness. Ultimately, they advocate for shared decision-making in ICD selection tailored to patient needs.

This editorial analyzes the PRAETORIAN trial, a noninferiority study comparing transvenous implantable cardioverter-defibrillators (ICDs) with subcutaneous ICDs in patients eligible for either device. Both systems showed similar efficacy in preventing arrhythmic sudden death, with comparable rates of the composite endpoint device-related complications and inappropriate shocks. However, transvenous ICDs had more lead-related issues, while subcutaneous ICDs experienced more inappropriate shocks. The authors discuss limitations of the trial, including industry funding, short follow-up, and exclusion of patients needing pacing. They highlight opportunities for future improvements in device programming and sensing algorithms and consider broader factors such as device size, longevity, pacing capabilities, and cost-effectiveness. Ultimately, they advocate for shared decision-making in ICD selection tailored to patient needs.