Quantitative Vector Screening to Improve Sensing and Reduce Inappropriate Shocks With the Subcutaneous Implantable Cardioverter Defibrillator

Background: The subcutaneous Implantable Cardioverter Defibrillator (S-ICD) offers protection from sudden cardiac death without transvenous leads. Although contemporary techniques and programming have reduced inappropriate shocks, high rates persist in certain populations. The objective of this study was to evaluate the impact of a novel quantitative vector screening (QVS) protocol on the incidence of sensing-related complications and inappropriate shocks in patients undergoing S-ICD implantation. Methods: We analyzed 223 consecutive patients who underwent S-ICD implantation at the Hospital of the University of Pennsylvania from December 2018 to July 2025. Traditional vector screening was used before 2023. In 2023, we implemented QVS, which incorporated quantitative sensing scores for each candidate and raised the threshold for S-ICD implantation. The primary end point was time to first inappropriate shock or under-sensed ventricular arrhythmia. Secondary outcomes included SMART Pass deactivation and need for device revision. Outcomes were reported as survival analyses. Results: During preimplant screening, the QVS protocol reduced patient eligibility from 96% to 83%. The median follow-up after implant was 42 months (interquartile range, 48) in the traditional vector screening arm and 18 months (interquartile range, 15) in the QVS arm. The primary end point of time to first inappropriate shock or under-sensed ventricular arrhythmia was longer in the QVS arm (log-rank, P =0.02). There were 23 primary end point events among 145 patients in the traditional vector screening arm (5.2 per 100 patient-years [95% CI, 3.1–7.4]) and 2 primary end point events among 78 patients in the QVS arm (1.8 per 100 patient-years [95% CI, 0.01–4.38]). Conclusions: Implementation of a novel S-ICD screening protocol with stricter eligibility thresholds reduced sensing-related complications, particularly inappropriate shocks.