New Horizons in Nontransvenous Arrhythmia Management: Aurora Extravascular ICD

Traditionally, transvenous implantable cardioverter-defibrillators (ICDs) have served as the cornerstone of sudden cardiac death treatment; however, transvenous implantable ICDs carry significant short- and long-term risks of complications associated with intravascular and intracardiac leads. Attempts to migrate from the transvenous components resulted in the development of the subcutaneous ICD, which successfully terminates life-threatening ventricular tachyarrhythmias. However, the subcutaneous ICD has limitations, including the need for higher defibrillation energy, a lack of bradycardic pacing, and a lack of antitachycardia pacing for terminating ventricular tachycardias. The Aurora Extravascular ICD (ICD, Medtronic, Minneapolis, MN) introduces a novel substernal lead placement and represents a notable advancement in the prevention of sudden cardiac death from ventricular tachyarrhythmias by integrating defibrillation therapy with short-term bradycardia and antitachycardia pacing capabilities without the need for transvenous leads. With the introduction of this novel device in clinical practice, anesthesiologists need to understand what makes the extravascular ICD system unique and how to manage it appropriately during the perioperative period.