Main text word count: 2293
Disclosures: Dr. Verma receives speaker honoraria from Medtronic, Biotronik, Zoll and Boston Scientific and consulting fees from Biosense Webster and AltaThera Pharmaceuticals. Dr. Knight receives speaker honoraria and consulting fees for Abbott, Baylis Medical, Biosense Webster, Boston Scientific, and Medtronic. Dr. Pfenniger receives speaker honoraria from Medtronic and Abbott. Dr. Passman receives research support from AHA (#18SFRN34250013), NIH (UG3HL165065), research support and speaker fees from Medtronic, research support from Abbott, and royalties from UpToDate. Dr. Lin receives research support and consulting fees from Medtronic. Dr. Kim receives speaker honoraria from Medtronic, Boston Scientific, and Abbott, and is on the advisory board for Boston Scientific. Dr. Patil receives consulting fees from Boston Scientific and speaker honoraria from Zoll Medical. Dr. Arora is on the board of directors and has ownership interest in Inomagen Therapeutics, receives royalties from UpToDate, and is on the board of directors and receives honoraria from the American Board of Internal Medicine. The remaining authors have nothing to disclose.
Funding Statement: This research was not supported by external funding.
Abstract 
Introduction : The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to a transvenous ICD in patients who meet criteria for ICD implantation without concurrent need for cardiac pacing. The objective of this study is to examine the rates of and indications for S-ICD removal and extraction.
Methods : A retrospective analysis of all patients who underwent S-ICD implantation between 2010 and 2022 at a single multihospital healthcare system was performed. The primary endpoint was S-ICD removal or extraction. Patient and device characteristics were abstracted from the electronic medical record.  Univariate and multivariate analyses were completed to determine factors associated with S-ICD extraction.
Results : A total of 372 patients (69.5% male; 48.6 ± 14.4 years old) underwent S-ICD implantation during the study period. There were 22 (5.9%) patients (81.8% male; 52.1 ± 13.2 years old) who underwent S-ICD extraction over a median follow up period of 4.4 [2.0-6.5] years. The median length of time between implantation and extraction was 39.6 [8.3-64.6] months. The most common indications for S-ICD extraction were need for bradycardia pacing (incidence, 1.08%), infection (1.34%), and inappropriate shocks due to oversensing (1.34%). A smoking history and higher body mass index were independently associated with S-ICD extraction.
Conclusions : The overall rate of S-ICD extraction over 4.4 [2.0-6.5] years was 5.9%, with the most common indications for extraction being need for bradycardia pacing, infection, and inappropriate shocks due to oversensing. A smoking history and high body mass index are associated with increased rates of S-ICD extraction. With appropriate patient selection for the S-ICD, the need to remove the device after implantation is low.
Key Words: subcutaneous, ICD, extraction, rate, indications