Subcutaneous and Extravascular Implantable Cardioverter-Defibrillators: A Clinical Framework for Breast Surgery, Pregnancy, Lactation, Radiation Therapy, and Breast Imaging

The subcutaneous implantable cardioverter-defibrillator and extravascular implantable cardioverter-defibrillator do not require intravascular, intracardiac, or epicardial leads, making them attractive alternatives to transvenous implantable cardioverter defibrillators in patients without bradycardia pacing or cardiac resynchronization therapy indications. These systems are especially useful for patients with venous access challenges and those at risk for endovascular infections, including patients with renal failure or those who are immunocompromised. Women with prior or anticipated breast surgery, such as mastectomy or breast reconstruction surgery, or those who are lactating present unique anatomic, procedural, and post-operative quality-of-life considerations. This commentary provides a practical, scenario-based framework for managing this unique patient group. Key considerations include individualized incision and pulse generator planning, proactive multidisciplinary coordination, procedure-specific management, and shared decision-making in patients with prior or anticipated breast augmentation or reduction, pregnancy, lactation, mastectomy, radiation therapy, and breast imaging.