Prior Sternotomy in Transvenous Lead Extraction: Risk Analysis Tempered by Clinical Experience.

Transvenous lead extraction (TLE) is a complex yet effective procedure to remove indwelling leads belonging to cardiac devices with a potential for serious complications. Consequently, the 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction maintains that TLE be performed only at centers with an environment fully supportive of a lead extraction program, which includes a team-based approach, incorporating equipment and capable of managing all potential complications.1 An experienced center will evaluate the patient based on the current presentation and comorbid conditions, while incorporating the procedural and patient-related risks. Despite our best evaluation and preparation, however, a flawless risk stratification approach for those in consideration for TLE remains elusive. Patients with prior sternotomy (PS) is a group of interest due to theoretical mediastinal scarring which may protect against vascular tears and conversely increased adhesions and fibrosis which may delay precious life-saving surgical access after vascular complication from TLE. Historically, patients with PS have been shown to have increased operative morbidity and mortality. In a Swiss cohort undergoing coronary artery bypass grafting, postoperative mortality rate was 9.6% (57/594) in PS compared with 2.8% (87/3184) in those with no prior sternotomy (NPS). Low cardiac output syndrome, intraaortic balloon pump support, prolonged ventilatory support (>24 hours), hemorrhage and gastrointestinal complications were prominent features in those with PS as compared with those undergoing primary coronary artery bypass grafting. While some recently published data may suggest PS as a predictor of clinical success in the setting of TLE, there continues to be a significant risk of urgent cardiac surgery—which carries high mortality, and appropriate planning with cardiothoracic backup is crucial.3,4 In this issue, Tsang et al5 present a single-center experience with prior sternotomy on outcomes in transvenous lead extractions. Of 1480 patients undergoing TLE, 455 had PS and were more likely to be male and have more comorbid conditions (coronary artery disease, hypertension, diabetes mellitus, and chronic kidney disease) than those with NPS. Patients with PS were more likely to have defibrillator leads (70.1% versus 62.3%; P=0.004) and more leads extracted per case (2.1±1.0 versus 1.9±0.9; P=0.006) though mean lead dwell time was similar between patient groups. Despite some baseline differences, procedural success rates were similar in both groups, 97.6% in the PS versus 98.4% in the NPS group (P=0.257). Major complications occurred in 9 (2.0%) PS patients and 23 (2.2%) patients with NPS (P=0.746). Notably, patients with EDITORIAL