When You Have Nowhere to Look, You Look Where You Can

While many physicians implant cardiac implantable electronic devices (CIED), only a small fraction performs transvenous lead extraction (TLE). This has led to inconsistent and, at times, inappropriate patient management. Despite clear Class I recommendations for lead extraction for infected devices,(1) patients all too often receive multiple debridements and rounds of antibiotics for device-related infection. In addition, in cases of device system upgrade and lead malfunction, lead after lead is often added, sometimes involving tunneling and frequently resulting in the elimination of vascular access. Why are more of these patients not offered or referred for, lead extraction? In many cases, we believe it is driven by unfounded fear of the procedure as well as a knowledge gap. In a survey performed by Spectranetics (Colorado Springs, CO), cardiologists perceived the major complication rate associated with the extraction procedure itself to be greater than 5% and the mortality rate to be nearly 1.5%. Henrikson and colleagues performed a similar survey among 252 electrophysiologists (63% of whom identified themselves as performing TLE) with similar observations.(2) More than 75% of respondents perceived the morbidity risk associated with TLE to be ≥2% and close to 30% of respondents estimated the risk to be ≥5%. Among the group surveyed, the mortality risk with TLE was similarly perceived to be excessive despite the surprising preponderance of "extractionists" among the group. It is not surprising that more patients are not referred if this is the impression. In a global survey of 820 clinicians addressing the understanding of CIED infection and lead management, 50% or less of all respondents failed to correctly identify and implement Class I recommendations for device-related infection despite >60% of respondents identifying themselves as performing TLE.(3) Clearly what is needed are data and education, both of which are lacking. In this issue of Circulation, Deshmukh and colleagues rightfully recognize that "limited data exist regarding trends in utilization and adverse outcomes outside the centers of considerable experience" and attempt to extend the available data with observations from a retrospective, descriptive study utilizing a national, large, administrative database.(4).