# Totally Fluoroless Versus Limited Fluoroscopy-assisted Implantation: Identifying the Role of Fluoroscopy During Subcutaneous Implantable Cardioverter-defibrillator Implantation

## TL;DR

This study compares two methods for implanting subcutaneous defibrillators and finds both are equally safe and effective.

## Contribution

Demonstrates that implanting subcutaneous defibrillators without fluoroscopy is as effective and safe as using limited fluoroscopy.

## Key findings

- Totally fluoroless implantation achieved 100% success in defibrillation testing at 60 J.
- Both methods showed similar low rates of inappropriate shocks and no major complications.
- Fluoroless implantation is a viable alternative to fluoroscopy-guided implantation.

## Abstract

The subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as an alternative to conventional ICD systems. Although not considered mandatory, short-time fluoroscopy is used in clinical practice, both preprocedurally and intraoperatively. The aim of this study was to compare totally fluoroless versus limited fluoroscopy-assisted S-ICD implantation in terms of clinical and technical efficacy and safety. In this non-randomized, single-center study, 49 patients (24.5% women; mean age, 43.2 ± 18.4 years) at high risk for arrhythmic cardiac death underwent S-ICD implantation in the context of either primary or secondary prevention between May 2016 and June 2024 with at least 6 months of follow-up thereafter. Patients were allocated to group A (n = 25), where a totally fluoroless implantation strategy was followed (January 2023–June 2024), or group B, where a limited fluoroscopy–guided S-ICD implantation process (first 24 cases) was followed. Following implantation, a pre-discharge chest X-ray confirmed an anatomically acceptable lead position in all cases. Further, our data revealed similar acute and long-term clinical efficacy with both approaches: the success rate of defibrillation testing at 60 J was 100%, the appropriate shock rate was low (8.2%) with defibrillation therapy successful in all cases, the mean PRAETORIAN score remained in the low-risk category, and no arrhythmic deaths were recorded. The rate of inappropriate shocks was similar between groups (8% vs. 8.3%; P = .97 for groups A and B, respectively). Finally, no major periprocedural complications were recorded with either approach. Compared to the limited fluoroscopy–guided technique, totally fluoroless S-ICD implantation showed comparable efficacy, reliability, and safety in the present study.