Patients requiring permanent pacing after tricuspid valve intervention present challenges due to the need to cross tricuspid valve prostheses. We report three cases of successful dual coronary sinus (CS) lead implantatio...Patients requiring permanent pacing after tricuspid valve intervention present challenges due to the need to cross tricuspid valve prostheses. We report three cases of successful dual coronary sinus (CS) lead implantation for biventricular pacing following a range of tricuspid interventions-surgical tricuspid annuloplasty, transcatheter edge-to-edge repair, and transcatheter tricuspid valve replacement. The approach avoided tricuspid valve traversal, was technically feasible and resulted in satisfactory pacing performance without procedural complications. Dual CS lead configurations were individualized based on CS anatomy and pacing characteristics. The degree of QRS narrowing achieved varied according to lead location and ventricular activation patterns, highlighting the importance of individualized lead placement strategies and device programming. Dual CS lead pacing may represent a viable alternative for biventricular pacing in selected patients with prior tricuspid valve interventions. Larger studies are needed to evaluate long-term outcomes and define the optimal role of this approach among available pacing strategies in this patient population.
This report summarizes the case of a neonate with neonatal lupus erythematosus (NLE) and complete third-degree atrioventricular block who underwent permanent pacemaker implantation via an epicardial approach. It focuses...This report summarizes the case of a neonate with neonatal lupus erythematosus (NLE) and complete third-degree atrioventricular block who underwent permanent pacemaker implantation via an epicardial approach. It focuses on the etiology, indications for intervention, and surgical procedure, and evaluates the feasibility of using the 3830 lead for epicardial permanent pacing in pediatric patients.
INTRODUCTION: Pulmonary vein isolation (PVI) alone achieves modest arrhythmia freedom in persistent atrial fibrillation (PeAF). Cryoballoon ablation (CBA) offers a single-shot alternative to radiofrequency ablation (RFA)...INTRODUCTION: Pulmonary vein isolation (PVI) alone achieves modest arrhythmia freedom in persistent atrial fibrillation (PeAF). Cryoballoon ablation (CBA) offers a single-shot alternative to radiofrequency ablation (RFA) that streamlines procedural workflow. We aimed to quantify the clinical efficacy, procedural efficiency, and safety of CBA versus RFA through a meta-analysis of randomized controlled trials (RCTs). METHODS AND RESULTS: Systematic review of PubMed, Embase, and Scopus identified 5 RCTs enrolling 1,091 patients (515 CBA, 576 RFA). The primary endpoint was 12-month freedom from any atrial arrhythmia, with isolated AF, and atrial tachycardia/flutter evaluated as secondary endpoints. Random-effects models generated relative risks (RRs) and mean differences (MDs) with 95% confidence intervals (CI). Time-to-event data were pooled using a generic inverse-variance approach to derive hazard ratios (HR). CBA and RFA demonstrated equivalent freedom from any arrhythmia (RR 0.97, 95% CI 0.81-1.15; p = 0.71). Time-to-event analysis corroborated a comparable recurrence hazard (HR 0.91, 95% CI 0.67-1.24; p = 0.56; I = 0%). Repeat ablation rates were identical (RR 0.93; p = 0.50). CBA significantly reduced procedural time (MD -45.37 min; p < 0.0001), while major complications were comparable (1.5% vs. 2.7%; p = 0.18). Trial sequential analysis indicated that further randomization is unlikely to demonstrate superiority. CONCLUSION: In PeAF, CBA and RFA achieve equivalent 12-month arrhythmia-free survival and comparable repeat-ablation rates, while CBA confers a highly significant reduction in procedural time. However, reliance on 12-month follow-up and heterogeneous rhythm surveillance protocols may limit assessments of true long-term durability.
OBJECTIVE: The head-up tilt test (HUTT) diagnoses Vasovagal Syncope (VVS) but its duration limits adoption. We evaluated a shortened HUTT protocol in patients from Central China. METHODS AND RESULTS: We retrospectively a...OBJECTIVE: The head-up tilt test (HUTT) diagnoses Vasovagal Syncope (VVS) but its duration limits adoption. We evaluated a shortened HUTT protocol in patients from Central China. METHODS AND RESULTS: We retrospectively analyzed 614 patients (median age 53.5 years, 53.2% female) with suspected VVS. All underwent a standardized HUTT with a 10 min passive phase at 70°, followed, if negative, by a 15 min active phase with 0.5 mg sublingual nitroglycerin. The overall positivity rate was 60.91% (374/614), with the vast majority (359/374) of positive responses occurring during the active phase. The median positive response time was 10 min (IQR: 6.5-10) for the passive phase and 3 min (IQR: 2-5min) for the active phase, with peak incidences observed at these intervals. The positivity rates for the 10 min and 15 min active phases were 58.63% and 60.91%, respectively, with no statistically significant difference (p = 0.449). Through generalized additive model (GAM) analysis with inflection point detection, a significant nonlinear relationship between time and positivity was identified (EDF = 2.302, p < 0.001). Independent predictors of a positive test included female gender, increasing age, prior syncope before HUTT, and lower systolic blood pressure at 10 min of the passive phase. CONCLUSION: Our shortened HUTT protocol achieved comparable diagnostic yield in these patients while reducing test duration. Compared with the consensus-recommended protocol, the shortened HUTT protocol saved at least 37.5% of the total test time, while achieving a positive rate (60.91%).
Congenital long QT syndrome (LQTS) is associated with ventricular arrhythmias and increased risk of sudden cardiac death. Beta-blockers are first-line therapy, although intolerance may occur. We report a case of a 50-yea...Congenital long QT syndrome (LQTS) is associated with ventricular arrhythmias and increased risk of sudden cardiac death. Beta-blockers are first-line therapy, although intolerance may occur. We report a case of a 50-year-old man with LQTS and subcutaneous implantable cardioverter-defibrillator (S-ICD) who experienced recurrent appropriate therapies and beta-blocker intolerance due to bradycardia. An atrial leadless pacemaker was implanted while maintaining the S-ICD, achieving a double-device strategy without intracardiac leads. This approach resulted in QTc shortening, symptom improvement, and complete suppression of further ICD therapies. This strategy may represent a feasible and effective alternative in selected LQTS patients requiring atrial pacing.
BACKGROUND: Pulmonary vein isolation (PVI) for atrial fibrillation (AF) is performed under general anesthesia (GA) or conscious sedation (CS). Prior studies have linked anesthesia type to postoperative recurrence and cat...BACKGROUND: Pulmonary vein isolation (PVI) for atrial fibrillation (AF) is performed under general anesthesia (GA) or conscious sedation (CS). Prior studies have linked anesthesia type to postoperative recurrence and catheter metrics, but not to catheter swing, interlesion distance (ILD), or acute pulmonary vein reconnection. We assessed how GA versus CS relates to intraoperative catheter stability, lesion continuity, and clinical outcomes. METHODS: This retrospective study included 147 patients undergoing first-time PVI (97 under GA, 50 under CS). We evaluated and compared catheter swing, contact force (CF), ablation index (AI), ILD, acute pulmonary vein reconnection, and 12-month recurrence between groups. RESULTS: Catheter swing (all segments p < 0.001), ILD (all segments p < 0.001), and acute pulmonary vein reconnection (20.6% vs. 54.0%, p < 0.001) were significantly lower in the GA group, which was associated with a higher postoperative success rate (12-month recurrence: 23.7% vs. 44.0%, p = 0.007). Anesthesia type was significantly associated with both acute pulmonary vein reconnection (OR 0.22, p < 0.001) and postoperative success (12-month OR 0.40, p = 0.013). Furthermore, catheter swing was significantly associated with acute pulmonary vein reconnection (OR 1.16, p < 0.001), which served as a crucial mediator between anesthesia strategy and overall postoperative success. CONCLUSIONS: In this retrospective cohort, GA was associated with reduced catheter swing, shorter ILD, and lower acute pulmonary vein reconnection compared to CS. Acute reconnection significantly mediated the association with 12-month freedom from AF. These findings suggest that GA may facilitate more durable lesion formation during PVI.
A 68-year-old man with mirror-image dextrocardia and symptomatic, drug-refractory paroxysmal atrial fibrillation underwent zero-fluoroscopy cryoballoon ablation. Intracardiac echocardiography and 3D electroanatomic mappi...A 68-year-old man with mirror-image dextrocardia and symptomatic, drug-refractory paroxysmal atrial fibrillation underwent zero-fluoroscopy cryoballoon ablation. Intracardiac echocardiography and 3D electroanatomic mapping were used to guide transseptal puncture, navigate the mirror-image anatomy, and confirm pulmonary vein occlusion. All four pulmonary veins were successfully isolated without complications. At 1-year follow-up, the patient remained asymptomatic without antiarrhythmic medication. This case demonstrates the feasibility and safety of a completely fluoroless cryoballoon ablation strategy in a patient with dextrocardia, effectively overcoming the challenges of complex congenital cardiac anatomy.
Vein of Marshall (VOM) ethanol ablation is an effective adjunctive therapy for persistent atrial fibrillation and mitral-isthmus dependent atrial flutter; however, physicians often encounter technical challenges during V...Vein of Marshall (VOM) ethanol ablation is an effective adjunctive therapy for persistent atrial fibrillation and mitral-isthmus dependent atrial flutter; however, physicians often encounter technical challenges during VOM cannulation, including coronary sinus (CS) sheath disengagement during manipulation which may complicate the procedure and reduce efficiency. Our case series describes a simplified and stability focused technique that utilizes a 10 French bidirectional deflectable sheath (Medtronic Flexcath Contour) that is supported by a Terumo Glide Advantage wire to enhance CS stability. Our approach was used in three patients aged 62-74 years old, two of which were females and had persistent symptomatic atrial fibrillation and atrial flutter that were refractory to prior ablations and medical therapy. In these cases, anatomical challenges including prominent Eustachian ridges (inferred from initial cannulation difficulties and sheath instability during CS access) and variable VOM positions were identified via CS venography, contributing to cannulation difficulty. In all three cases, our technique allowed for stable CS access and successful VOM identification, facilitating cannulation, wire advancement, balloon placement, and ethanol infusion without any sheath disengagement. We used pre and post infusion voltage mapping which ultimately showed elimination of all potentials along the lateral mitral isthmus and ridge. There were no procedure complications, including those potentially associated with sheath advancement into the CS such as vessel trauma or perforation, and all patients were atrial arrhythmia free at 3- and 6-month follow-up. Our technique of using a larger-lumen deflectable bidirectional sheath with guidewire support provides enhanced catheter stability and may improve procedural efficiency, reduce cannulation time, contrast utilization, and fluoroscopy particularly in anatomically challenging cases.
INTRODUCTION: Transvenous pacemakers are effective but carry significant short- and long-term complications. Leadless pacemakers were developed to overcome these limitations, however, data in high-risk patients ineligibl...INTRODUCTION: Transvenous pacemakers are effective but carry significant short- and long-term complications. Leadless pacemakers were developed to overcome these limitations, however, data in high-risk patients ineligible for transvenous systems remain limited. AIM: To evaluate the real-world outcomes of leadless pacemaker in high risk bradyarrhythmia patients unsuitable for transvenous pacing. METHODS: A retrospective, observational, multi center registry (MLPI) across four Israeli hospitals, included all patients undergoing leadless pacemaker implantation July 2021-December 2022 within a national pilot program. Indications included venous abnormalities, prior device infection, Twiddler's syndrome or high infection risk. Procedural success, complications, electrical performance, and mortality were assessed at 48 h, 30 days, and 12 months. RESULTS: A total of 138 patients were enrolled, with a high comorbidity burden (hypertension 74%, heart failure 44%, chronic kidney disease 36%). High grade atrioventricular block was the main pacing indication (70%), and the leading reason for leadless implantation (54%) was high infection risk. Implantation was successful in 98% of the patients, almost all with Micra. Acute complications occurred in 2.9%, (primarily pericardial effusion); three patients (2.2%) died within 48 h. At 1-year, electrical performance remained stable, with low pacing thresholds (median 0.5 V), preserved sensing, and declining impedance. Two late complications occurred (tamponade, loss of capture). The 1-year cumulative complication rate was 4.7%, and all-cause mortality 12.3%. CONCLUSION: Leadless pacemaker implantation in a very high-risk Israeli cohort achieved high procedural success, stable performance, and low complication rate, supporting its role as a safe and effective alternative to conventional pacing systems.
BACKGROUND: Early-onset atrial fibrillation/flutter (AF/AFL), defined as AF/AFL onset before age 45 years, can lead to adverse outcomes including heart failure (HF). The sex-specific patterns of early-onset AF/AFL and as...BACKGROUND: Early-onset atrial fibrillation/flutter (AF/AFL), defined as AF/AFL onset before age 45 years, can lead to adverse outcomes including heart failure (HF). The sex-specific patterns of early-onset AF/AFL and associated HF remain poorly understood, particularly in comparison with late-onset AF/AFL. METHODS: Using data from Global Burden of Disease (GBD) 2021, we report the age-standardized rates (ASRs) per 100,000 population and changes from 1990 to 2021 based on sexes, regions and 204 countries. The contributions of risk factors, decomposition methodology, slope index of inequality and Bayesian age-period-cohort models were utilized to assess epidemiological trends, sex disparities, and projected burdens to 2050. All the analyses were performed in both early-onset and late-onset AF/AFL. RESULTS: Globally, the total number of early-onset AF/AFL incident cases was 204 thousand in 2021, accounting for 4.5% of all cases. The male-to-female ratio in global prevalence ASR was 1.62, which suggested greater sex disparities than late-onset AF/AFL. Sex-specific risk factors included smoking and high alcohol use in males and high BMI in females. The global prevalence ASR of associated HF showed a sustained increase through 2050, with a female predominance. CONCLUSION: The epidemiological patterns in early-onset AF/AFL exhibited significant sex-specific variations and differed from those observed in late-onset AF/AFL. Future efforts should prioritize early detection, risk stratification, and tailored interventions to curb complications, particularly HF progression.
The lack of dedicated generators for conduction system pacing can force the use of unconventional device configurations in selected patients. We report the case of a 74-year-old pacing-dependent man with non-ischemic car...The lack of dedicated generators for conduction system pacing can force the use of unconventional device configurations in selected patients. We report the case of a 74-year-old pacing-dependent man with non-ischemic cardiomyopathy who underwent an upgrade to LBBAP-ICD, programmed in AAI(R) mode. Syncope occurred after a nonsustained ventricular tachycardia episode due to activation of the Ventricular Tachycardia Response algorithm in a Boston Scientific ICD. This case highlights a potential interaction between device algorithms and pacing configuration that may result in clinically significant pauses in pacing-dependent patients.
INTRODUCTION: Left bundle branch block (LBBB) is a conduction abnormality that alters the pattern of left ventricular (LV) activation and contraction, leading to ventricular remodeling, typically manifesting as LV hypert...INTRODUCTION: Left bundle branch block (LBBB) is a conduction abnormality that alters the pattern of left ventricular (LV) activation and contraction, leading to ventricular remodeling, typically manifesting as LV hypertrophy and dilatation. This remodeling is often associated with progressive cardiac dysfunction and a poor prognosis. AIM: To compare temporal changes in left ventricular strain patterns in patients with typical and atypical LBBB over a period of two years. METHODS: Electrocardiographic, echocardiographic, and strain parameters were obtained at two-year follow-up from previously enrolled patients. RESULTS: Of the 181 patients initially enrolled, 152 were contacted telephonically. Among them, 23 patients underwent follow-up evaluation, 4 patients received cardiac resynchronization therapy (CRT), and 21 deaths were recorded. Significant changes between baseline and follow-up were observed in left ventricular end-diastolic dimension (LVEDD), left ventricular filling time (LVFT), LVFT/R-R interval, three-dimensional systolic dyssynchrony index (SDI), and left ventricular ejection fraction (EF). Compared with survivors, non-survivors had significantly lower baseline EF, and global longitudinal strain (GLS). An ALEF ≤40% was identified as a significant predictor of mortality. Multivariable regression analysis demonstrated that ALEF, GLS, and age were independent predictors of mortality. CONCLUSION: The all-cause mortality rate over two years among patients with LBBB was 13.8%. Age, ALEF, and GLS were significant predictors of mortality. Improvements in left ventricular function and ventricular dyssynchrony were observed during follow-up; however, the factors contributing to these changes could not be determined from the present study. TRIAL REGISTRATION: Clinical Trials Registry-India on 02/05/2023 under the reference number CTRI/2023/05/052206.
BACKGROUND: Focal atrial tachycardia (AT) originating from a right atrial appendage (RAA) diverticulum is rare in children and often poses significant challenges for conventional radiofrequency catheter ablation (RFCA) d...BACKGROUND: Focal atrial tachycardia (AT) originating from a right atrial appendage (RAA) diverticulum is rare in children and often poses significant challenges for conventional radiofrequency catheter ablation (RFCA) due to limited catheter access and poor tissue contact. We report the successful use of transcatheter 95% ethanol chemical ablation as a bailout strategy in a child with recurrent AT and suspected arrhythmia-induced cardiomyopathy (AIC). CASE PRESENTATION: A 10-year-5-month-old boy with a history of incessant AT and severe left ventricular dysfunction (LVEF 23%) was diagnosed with suspected AIC. Although initial RFCA successfully terminated the tachycardia, AT recurred 2.5 months later. Repeat electrophysiological study with high-density mapping localized the earliest activation to the RAA roof. Intraprocedural right atrial angiography revealed a transversely oriented diverticulum-like sac arising from the RAA roof, communicating with the prior ablation site and preventing stable catheter engagement. Transcatheter chemical ablation was performed using an ST Blue ablation catheter positioned at the ostium of the diverticulum-like structure. After confirmation of selective contrast opacification without extravasation, a test bolus of 1 mL 95% ethanol was infused, resulting in immediate termination of the AT. A total of approximately 10 mL ethanol was delivered incrementally. Consolidation radiofrequency applications were then performed at the ostium to electrically isolate the ablated region. The procedure was uneventful, with no complications. Post-procedural monitoring confirmed non-inducibility of AT, and the patient remained arrhythmia-free at short-term follow-up with stable left ventricular function. CONCLUSION: This case demonstrates the feasibility and efficacy of bailout transcatheter ethanol ablation for recurrent AT arising from an inaccessible RAA diverticulum-like structure in a pediatric patient with AIC. Intraprocedural angiography was crucial for identifying the anatomical substrate. Ethanol chemical ablation may serve as a safe and effective alternative when conventional catheter ablation fails due to complex anatomy.
BACKGROUND: Ventricular tachycardia (VT) ablation outcomes in nonischemic cardiomyopathy (NICM) may differ by disease phenotype, but prior studies have pooled NICM as a single entity. We performed a phenotype-stratified...BACKGROUND: Ventricular tachycardia (VT) ablation outcomes in nonischemic cardiomyopathy (NICM) may differ by disease phenotype, but prior studies have pooled NICM as a single entity. We performed a phenotype-stratified meta-analysis of VT ablation outcomes across six major NICM subtypes. METHODS: We systematically searched PubMed, Embase, and the Cochrane Library through January 2026. Studies were stratified by phenotype: lamin A/C (LMNA), cardiac sarcoidosis, dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy (HCM), myocarditis, and arrhythmogenic right ventricular cardiomyopathy (ARVC). The primary outcome was VT recurrence. Proportions were pooled using restricted maximum likelihood estimation on the logit scale. Phenotype differences were tested via mixed-effects meta-regression. RESULTS: Eighteen studies (1699 patients) met inclusion criteria after rigorous center-level overlap resolution. VT recurrence differed significantly across phenotypes (F [5,12] = 3.78, p = 0.027). LMNA had the highest recurrence (82.6%; 95% CI 51.6%-95.5%; k = 5), followed by sarcoidosis (57.1%; 32.2%-78.8%; k = 2), DCM (42.7%; 24.1%-63.6%; k = 4), HCM (36.2%; 23.8%-50.7%; k = 2), myocarditis (34.5%; 27.3%-42.5%; k = 2), and ARVC (33.8%; 16.0%-57.9%; k = 3). Phenotype explained 44.7% of between-study heterogeneity. CONCLUSIONS: VT ablation outcomes in NICM varied by the underlying disease phenotype, with recurrence rates ranging from 82.6% in LMNA cardiomyopathy to 33.8% in ARVC. These hypothesis-generating findings argue against treating NICM as a unified category and provide a foundation for phenotype-specific procedural counseling and clinical trial stratification that warrants validation in prospective registries.
Fluoroscopy has long been the cornerstone imaging modality in cardiac electrophysiology (EP), enabling real-time catheter visualization but exposing patients and healthcare providers to ionizing radiation and significant...Fluoroscopy has long been the cornerstone imaging modality in cardiac electrophysiology (EP), enabling real-time catheter visualization but exposing patients and healthcare providers to ionizing radiation and significant occupational hazards. With the emergence of three-dimensional electroanatomic mapping (EAM) systems and intracardiac echocardiography (ICE), zero- and near-zero fluoroscopy (ZF) approaches have become increasingly feasible across a wide spectrum of EP and structural interventions. This review synthesizes current evidence supporting ZF workflows, highlighting their efficacy, safety, and expanding clinical applicability. Contemporary data demonstrate that ZF techniques achieve procedural success, complication rates, and long-term outcomes comparable to conventional fluoroscopy-guided procedures, while substantially reducing radiation exposure and mitigating associated risks such as malignancy, cataract formation, and orthopedic injury. Advances in mapping accuracy and real-time intracardiac imaging-including 3D and 4D ICE-have enhanced anatomical visualization, procedural precision, and early detection of complications. Despite these benefits, ZF workflows introduce unique challenges, including vascular access complications, catheter-related thrombus formation, and navigation errors due to EAM system limitations. Furthermore, certain complex procedures-such as epicardial access, lead extraction, and select device implantations-continue to rely on fluoroscopic guidance. Operator experience, learning curves, and the availability of fluoroscopic "bailout" strategies remain critical considerations. Overall, the transition toward ZF approaches represents a paradigm shift in EP, emphasizing radiation safety without compromising procedural outcomes. Continued technological innovation, standardized training, and robust randomized studies are essential to further validate and optimize these techniques, ultimately advancing safer, patient-centered cardiovascular care.
There is limited evidence in the literature regarding the safety and feasibility of transvenous extraction for leads malpositioned in the left heart for an extended period. This report presents a challenging case of a 44...There is limited evidence in the literature regarding the safety and feasibility of transvenous extraction for leads malpositioned in the left heart for an extended period. This report presents a challenging case of a 44-year-old male with a pacemaker pocket infection and bacteremia, in whom a previously unrecognized atrial lead malposition into the left atrium-present for 17 years-was identified and successfully extracted. This report suggests that percutaneous extraction of a long-standing, malpositioned lead in the left heart is both mandatory and feasible in the setting of cardiac implantable electronic device infection.
BACKGROUND: Patients with end-stage renal disease (ESRD) on dialysis face a high risk of sudden cardiac death, but traditional transvenous implantable cardioverter-defibrillators (TV-ICD) carry risks of central venous st...BACKGROUND: Patients with end-stage renal disease (ESRD) on dialysis face a high risk of sudden cardiac death, but traditional transvenous implantable cardioverter-defibrillators (TV-ICD) carry risks of central venous stenosis and infection. Subcutaneous implantable cardioverter-defibrillators (S-ICD) provide an extravascular alternative, though comparative outcomes in dialysis patients remain limited. METHODS: This study evaluated ESRD patients on hemodialysis who underwent S-ICD or TV-ICD implantation between January 2000 and March 2026 using the TriNetX global health network. A 1:1 propensity score matching (PSM) was utilized across 81 clinical covariates. Kaplan-Meier survival analysis and Cox proportional hazards regression were used to assess long-term outcomes, including infectious complications, dialysis access revisions, and mortality. RESULTS: Following PSM, 456 matched pairs (N = 912) of ESRD patients on dialysis were identified. There were no significant differences between the S-ICD and TV-ICD cohorts regarding the composite outcome of sepsis, bacteremia, or transvenous lead extraction (53.5% vs. 55.1%; p = 0.268). All-cause mortality (58.7% vs. 60.4%; p = 0.747) and hospitalization rates (87.9% vs. 85.4%; p = 0.874) were also similar between the groups. However, S-ICD was associated with higher rates of composite open and endovascular dialysis access revision (39.1% vs. 25.8%; p = 0.001), percutaneous dialysis access intervention (p = 0.002), and dialysis access surgery (p = 0.021). CONCLUSION: S-ICD and TV-ICD demonstrated similar rates of infectious complications, hospitalization, and all-cause mortality in ESRD patients. S-ICD implantation was associated with higher rates of dialysis access revisions and interventions. Device selection should remain individualized, guided by anatomy, access planning, and clinical context.
BACKGROUND: The Extravascular Implantable Cardioverter-Defibrillator (EV-ICD) utilizes a substernal lead to provide defibrillation and anti-tachycardia pacing (ATP) while avoiding transvenous complications. General anest...BACKGROUND: The Extravascular Implantable Cardioverter-Defibrillator (EV-ICD) utilizes a substernal lead to provide defibrillation and anti-tachycardia pacing (ATP) while avoiding transvenous complications. General anesthesia (GA) was applied for implantation procedures in the EV-ICD pivotal trial and is currently recommended by the manufacturer. However, GA carries specific risks and consumes significant resources. This study evaluates the feasibility, safety, and procedural efficiency of EV-ICD implantation performed under cardiologist-administered deep sedation with noninvasive ventilation (DS-NIV) compared to standard GA. METHODS: We retrospectively analyzed 24 consecutive patients undergoing EV-ICD implantation in our center. Patients received either GA (n = 14) or DS-NIV (n = 10) using a propofol-ketamine protocol delivered by cardiologists. Analyses focused on peri-procedural feasibility and safety, procedural workflow and anesthesia characteristics, and early device electrical performance. RESULTS: No anesthesia-related complications occurred in either group. The DS-NIV group demonstrated significantly shorter wheels-to-incision times (median: 45 vs. 70 min, p = 0.022), whereas the procedural duration did not differ significantly from the GA group. Patients receiving DS-NIV required fewer vasopressors (60% vs. 100%, p = 0.024) despite higher propofol infusion rates (800 vs. 350 mg/h, P<0.001). Defibrillation testing success and electrical parameters were comparable. In a median follow-up of 182 days two patients received appropriate EV-ICD therapies and no inappropriate ATP or shocks were delivered. CONCLUSION: EV-ICD implantation under cardiologist-administered DS-NIV appears to be feasible and safe, offering improved workflow efficiency compared to GA. These findings support deep sedation as a practical alternative in experienced centers, potentially expanding access to EV-ICD therapy.