Introduction: The ELECTRa registry indicated lower success rates and higher complication rates in low volume centres performing <30 transvenous lead extractions (TLE) per year. The UK lead extraction group met in 2018 to produce standards for lead extraction classifying procedures as low, medium or high risk. It recommended having a cardiac surgical team present for high risk cases and advised that high quality centres should have a successful lead extraction rate of >94%, procedural mortality rate of <0.8% and major complication rate of <1.7%. We present our TLE success and complication rates; overall, and according to procedural risk.
Methods: All TLE cases performed Nottingham University Hospitals from October 2010 (when our current electronic recording system was implemented) to March 2020 were audited with respect to patient and lead characteristics, indication, procedural details and outcomes. Cases were classified as “low”, “medium” and “high” risk according to the UK lead extractors consensus document.
Results: 139 TLE procedures were performed over 9.25 years (15 cases per annum) by 3 operators. Baseline characteristics: male 113 (81%); mean age 62 ± 17 years; BMI 24.8 ± 5.6 Kg/m2; severe left ventricular impairment 34 (24%); diabetic 20 (14%); cerebrovascular disease 11 (8%). Indication for extraction were non-infectious in 51 (37%); device erosion/pocket infection in 49 (35%) and systemic infection in 39 (28%). 260 leads were attempted, range 1–4, mean 1.87 per case. See Table 1 for lead and device characteristics. 47.5% of cases were classified as high risk, 45.3% medium risk and 7.2% low risk. Simple traction alone was used in 17 patients (12.2%), locking stylets in 26 (18.7%), mechanical sheaths in 78 (56.1%) and snares in 18 (12.9%). Overall clinical success rate was 97.8% (complete removal in 88.5%, fragment left in 9.4%), major complication rate 2.9%, minor complication rate 10.8%. There were 4 major complications – 3 cardiac tamponades (2 needing pericardiocentesis, 1 emergency sternotomy) and 1 failure to extract requiring semi-elective surgical input. There were no peri-procedural deaths. 7 patients died within 30 days of TLE; 6 of whom had TLE for systemic infection (relative risk 15.4, p=0.002). Major complication rates increased according to procedural risk group (0% low, 1.6% medium, 4.5% high) but success rate did not differ significantly (100% low, 98% medium, 97% high).
Conclusion: Nottingham University Hospitals is a low volume TLE centre. Despite this, our clinical success rate is higher than the expected standard (98 vs 94%). Our rate of major complications is higher than the expected standard (2.9 vs 1.7%) and may be a reflection of the large proportion of high-risk cases undertaken. Of our 66 high risk patients only 1 required an emergency sternotomy raising the question whether cardiac surgical team presence for all high-risk cases is an appropriate use of resources.