The downsized cardioverter defibrillators in early clinical trials in the United States are smaller and lighter than approved cardioverter defibrillators, but they remain relatively bulky. Prepectoral implantation of these devices may increase the risk of erosion, particularly in those patients with cardiac cachexia. This report describes a versatile technique for submuscular pectoral cardioverter defibrillator implantation using a lateral approach to the subpectoral space that has been used in 6 patients. Alternative surgical approaches for pectoral cardioverter defibrillator implantation and potential problems with these techniques are discussed.