The effect of centre volume and procedure location on major complications and mortality from transvenous lead extraction: an ESC EHRA EORP European Lead Extraction ConTRolled ELECTRa Registry subanalysis—Author’s reply

We read with interest the letter from colleagues Racine HP et al.¹ We acknowledge their comments that procedures performed by primary operator cardiologists in high-volume centres were more likely to be successful with a lower rate of procedure-related mortality supporting the need for transvenous lead extraction (TLE) to be performed in experienced centres with appropriate personnel present.

Racine HP et al. highlight the finding that when both a cardiologist and cardiothoracic surgeon were present, procedures were less likely to be successful and more likely to result in procedure-related major complications including cardiac/vascular avulsion or tear and procedural-related mortality. This is likely to be due to significant selection bias as procedures involving both a cardiologist and cardiothoracic surgeon are those deemed to be at higher procedural risk requiring the presence of access to cardiac surgery without delay. In keeping with this, these patients had longer lead dwell times and were more likely to require powered sheaths. Racine HP et al. reasonably state that there may have been additional lead characteristics placing these patients at higherrisk^2–4 that were not reported in the manuscript. We do not, however, feel that these findings support their conclusion of a poor collaboration between different specialists, i.e. cardiologist and cardiac surgeon. It should be noted that these procedures took place in a high-risk environment consisting of the operating room or hybrid theatre in the majority of cases (72.8%) with considerable planning to ensure the correct operators were present in an appropriate environment.

We completely agree with Racine HP et al. that complex, high-risk TLE procedures require a multidisciplinary team approach to ensure patient and lead characteristics are properly reviewed pre-procedurally to ensure appropriate case planning and manage potential complications with access to cardiac surgery without delay. A robust risk stratification of patients pre-procedurally and a close collaboration between cardiologist and cardiac surgeon is essential to improve outcomes for patients undergoing TLE.

Conflict of interest: B. Sidhu is funded by NIHR and has received speaker fees from EBR systems, outside the submitted work. J. Gould has received project funding from Rosetrees Trust, outside the submitted work. J. Gould, M. Elliott and V. Mehta have received fellowship funding from Abbott, outside of the submitted work. C. Kennergren has presented on behalf of, advised and performed studies with Spectranetics/Philips, outside of the submitted work. J.C. Deharo has received minor honoraria from Philips for lectures and consulting, outside of submitted work. A. Auricchio is a consultant to Boston Scientific, Backbeat, Biosense Webster, Cardiac, Corvia, Daiichi-Sankyo, EBR Systems, Medtronic, Merit, Microport CRM, Philips, and V-Wave; he received speakers’ fee from Daiichi-Sankyo, Boston Scientific, Biosense Webster, Medtronic, Microport CRM, and Philips; he participated in clinical trials sponsored by Boston Scientific, EBR Systems, Philips; he reports intellectual properties with Boston Scientific, Biosense Webster, and Microport CRM. Outside of the submitted work, K.H. Kuck reports grants and personal fees from St. Jude Medical, Biosense Webster and Medtronic, outside of the submitted work. C.A. Rinaldi receives research funding and/or consultation fees from Abbott, Medtronic, Boston Scientific, Spectranetics and MicroPort, outside of the submitted work.

Supplementary material

Supplementary material is available at Europace online.

References

Author notes