Beyond One-Size-Fits-All: Personalized Selection of Contemporary ICD Therapies

Since the first human implantation in 1980, implantable cardioverter-defibrillators (ICDs) have transformed the prevention of sudden cardiac death. Today, multiple ICD platforms are available, each with distinct strengths and limitations, making individualized device selection essential to optimize outcomes and minimize complications. The transvenous ICD (TV-ICD) remains the most established technology, offering reliable defibrillation, antitachycardia pacing (ATP), and pacing support, but is limited by lead-related complications and infection risk. The subcutaneous ICD (S-ICD) avoids intravascular leads and is particularly attractive in younger patients and those at high risk of infection, although it lacks ATP and has shorter device longevity. The extravascular ICD (EV-ICD) is an emerging alternative designed to combine the advantages of both systems by providing ATP and shock therapy without intravascular leads, though implantation is more complex and long-term evidence remains limited. Given these differences, ICD selection should be guided by patient-specific clinical characteristics rather than a one-size-fits-all approach. Key determinants include pacing indication, prior lead failure, infection risk, body mass index, age, and arrhythmic substrate. The proposed clinical pathway offers a practical framework to support tailored ICD selection by integrating these variables into a structured decision-making process. Such an individualized approach may improve patient outcomes, reduce device-related complications, and enhance the appropriate adoption of contemporary ICD technologies.