OBJECTIVES:Patients with congenitally corrected transposition of the great arteries (ccTGA) may undergo physiologic repair, leaving the right ventricle systemic, or anatomic repair, correcting the double discordance. We compared both strategies in an international study using propensity-score matching. METHODS:Patients from 12 European centres, aged <18 years, who underwent either physiologic or anatomic repair between 1990 and 2010 were included (n = 266). Patients were matched by optimal pair matching on ventricular septal defect, subpulmonary left ventricular outflow tract obstruction, ≥mild systemic tricuspid valve regurgitation, age, and gender, resulting in a 1:1 matched cohort of 162 patients. The resulting groups were compared for long-term survival, reoperations, and function of the systemic ventricle and atrioventricular valve. RESULTS:Transplant-free survival at 10 and 15 years was 87 ± 4%, 95% confidence interval (CI) [79%-95%] and 80 ± 6% [68%-93%] for the physiologic group and 85 ± 5% [78%-96%] and 85 ± 5% [78%-96%] for the anatomic group (P = .568). Freedom from cardiac reoperation at 10 and 15 years was 73 ± 6% [62%-85%] and 56 ± 8% [41%-75%] for the physiologic group and 61 ± 8% [47%-76%] and 36 ± 9% [26%-62%] for the anatomic group (P = .279). Tricuspid valve regurgitation at final follow-up was present in 57% (27/47) vs 17% (12/72), respectively (P < .001). CONCLUSIONS:Long-term survival and reoperation rates are similar in comparable patients following physiologic and anatomic repair of ccTGA in childhood. Tricuspid valve function may deteriorate when left in the systemic position following physiologic repair. In contrast, patients with tricuspid regurgitation may benefit from anatomic repair, with improved function in the subpulmonary position.

OBJECTIVES:Donation after circulatory death provides excellent patient outcomes in heart transplantation; however, warm ischaemic graft damage remains a concern. We have reported that a brief period of hypothermic oxygenated perfusion prior to normothermic reperfusion improves graft recovery in a rat model. Here, we investigated the cardioprotective benefits and mechanisms of this approach compared to the current clinical standard in a large animal model. METHODS:Circulatory death was induced in anaesthetized male Schweizer Edelschwein pigs (55 kg). Hearts underwent 20 min of warm, in-situ ischaemia, followed by a cold coronary flush and explantation. After 15 min backtable preparation, hearts underwent either 15 min cold static storage (control) or 30 min hypothermic oxygenated perfusion. All hearts were perfused ex vivo under normothermic conditions; 3 h in an unloaded mode, followed by 1 h with left ventricular loading to assess cardiac recovery. RESULTS:Compared to control conditions (n = 5), hypothermic oxygenated perfusion (n = 5) increased recovery of left ventricular function (cardiac output and maximum relaxation rate, P < 0.001 for both) and decreased cell death marker release (heart-type fatty acid binding protein, P = 0.009 and myoglobin, P < 0.001). In parallel, hypothermic oxygenated perfusion reduced the release of succinate and the oxidative stress marker 8-hydroxy-2'-deoxyguanosine. CONCLUSIONS:A brief period of hypothermic oxygenated perfusion, applied as a reperfusion therapy between graft procurement and normothermic machine perfusion, provides cardioprotection in a porcine model of donation after circulatory death. Hypothermic oxygenated perfusion is a promising, easily applicable, cardioprotective reperfusion strategy; this study provides key evidence to support clinical translation.

Donation after circulatory death (DCD) provides excellent patient outcomes in heart transplantation and substantially increases graft availability. The lack of validated biomarkers for graft function constrains reliable graft assessment and highlights the need for more effective assessment strategies. Using a porcine model of DCD, hearts underwent 0 (= sham), 10, 20, or 30 minutes of warm, in situ ischemia followed by normothermic ex situ heart perfusion (ESHP) for 3 hours in an unloaded mode and then 1 hour with left ventricular (LV) loading. During unloaded perfusion, LV function and the release of cell death markers were measured at regular intervals. These potential biomarker measurements were correlated with recovery outcomes determined at the end of loaded reperfusion. During unloaded ESHP, perfusate levels of heart-type fatty acid binding protein, and several catheter-based measurements of LV function, particularly LV work (calculated as the product of heart rate and developed pressure), correlated with functional recovery outcomes (P < .05 for all). We report several new biomarkers of cardiac graft quality, such as LV function and heart-type fatty acid binding protein, that are enabled by normothermic ESHP. These biomarkers are particularly promising as they are amenable to clinical application and may improve our precision in cardiac DCD graft evaluation.

The advent of normothermic, ex-situ heart perfusion (ESHP) enables new options for evaluation of cardiac grafts. Donation after circulatory death (DCD) is a promising solution to improve heart transplantation rates, but current ESHP evaluation approaches are recognized as suboptimal for DCD grafts. We aimed to develop a vascular function test for cardiac graft assessment during ESHP using a porcine model of DCD. Explanted hearts were perfused unloaded for 3 hours followed by left ventricular loading for 1 hour to measure cardiac recovery. During unloaded perfusion by pressure, hypercapnic vascular function tests were performed by briefly increasing CO2 levels and measuring responses in coronary flow. Coronary flow was effectively increased, it correlated with several measures of cardiac recovery (p≤0.05 for all) and was not affected by adenosine infusion. Our data provide the first evidence of a vascular function test that may help to improve evaluation of DCD cardiac grafts and is amenable to implementation in current clinical protocols.

Background Minimally invasive thoracotomies to repair selected congenital heart defects are considered only a cosmetic alternative approach by many; however, they represent the routine alternative in centers of expertise. Methods Pooled institutional data from the European Congenital Heart Surgeons Association using mini-thoracotomy approaches were analyzed since the beginning of their respective experiences until an inclusion surgical date of January 31, 2024, allowing at least six months postoperative follow-up. Results From 1999 to 2024, 3,007 patients from 11 centers underwent surgery. Age and weight ranged from 4 days to 73 years and 3.1 to 106 kg, respectively. Repaired defects included atrial and ventricular septal defects, partial anomalous pulmonary venous return, partial and complete atrioventricular septal defects, double-chambered right ventricle, cor triatriatum, scimitar syndrome, subaortic stenosis, and total anomalous pulmonary venous return (TAPVR). There was no surgical mortality or intraoperative conversion to sternotomy. Complications included wound infections (0.59%), pacemaker requirement (0.23%), phrenic nerve injury (0.26%), bleeding requiring exploration (0.13%), and neurologic injury (0.29%). Early or late reoperations were needed in 0.73%. Conclusion Minimally invasive thoracotomies are the preferred approach for selected congenital heart defects in the participating pediatric heart centers. Mini-thoracotomy incisions allow safe access to an ever-expanding spectrum of quality repairs, low morbidity, superior cosmetics, and early return to functionality in infants, children, and adults.

OBJECTIVESA second paediatric report has been generated from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). The purpose of EUROMACS, which is operated by the European Association for Cardio-Thoracic Surgery, is to gather data related to durable mechanical circulatory support for scientific purposes and to publish reports with respect to the course of mechanical circulatory support therapy. Since the first report issued, efforts to increase compliance and participation have been extended. Additionally, the data provided the opportunity to analyse patients of younger age and lower weight.METHODSParticipating hospitals contributed pre-, peri- and long-term postoperative data on mechanical circulatory support implants to the registry. Data for all implants in paediatric patients (≤19 years of age) performed from 1 January 2000 to 1 July 2019 were analysed. This report includes updates of patient characteristics, implant frequency, outcome (including mortality rates, transplants and recovery rates) as well as adverse events including neurological dysfunction, device malfunction, major infection and bleeding.RESULTSTwenty-nine hospitals contributed 398 registered implants in 353 patients (150 female, 203 male) to the registry. The most frequent aetiology of heart failure was any form of cardiomyopathy (61%), followed by congenital heart disease and myocarditis (16.4% and 16.1%, respectively). Competing outcomes analysis revealed that a total of 80% survived to transplant or recovery or are ongoing; at the 2-year follow-up examination, 20% died while on support. At 12 months, 46.7% received transplants, 8.7% were weaned from their device and 18.5% died. The 3-month adverse events rate was 1.69 per patient-year for device malfunction including pump exchange, 0.48 for major bleeding, 0.64 for major infection and 0.78 for neurological events.CONCLUSIONSThe overall survival rate was 81.5% at 12 months following ventricular assist device implant. The comparison of survival rates of the early and later eras shows no significant difference. A focus on specific subgroups showed that survival was less in patients of younger age (<1 year of age) (P = 0.01) and lower weight (<20 kg) (P = 0.015). Transplant rates at 6 months continue to be low (33.2%) The fact that the EUROMACS registry is embedded within the European Association for Cardio-Thoracic Surgery Quality Improvement Programme offers opportunities to focus on improving outcomes.

OBJECTIVES:We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). METHODS:In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. RESULTS:The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was -0.34 (95% CI -0.50 to -0.18) in the USAT and -0.53 (95% CI -0.68 to -0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032-0.271; Pnon-inferiority = 0.80; Psuperiority = 0.013). Mean change in Qanadli pulmonary occlusion score was -7.23 (95% CI -9.58 to -4.88) in the USAT and -11.36 (95% CI -15.27 to -7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44-9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. CONCLUSIONS:In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.

Background: There is a shortage of donor hearts in Switzerland, especially for pediatric recipients. However, the rate and reason for refusals of pediatric donor hearts offered in Switzerland has not been systematically analyzed. Methods: The national transplant database, Swiss Organ Allocation System, was searched for all hearts from Swiss and foreign donors younger than 16 years from 2015 to 2020. The numbers of accepted and refused hearts and early outcome were assessed, and the reasons for refusal were retrospectively analyzed. Results: A total of 136 organs were offered to the three Swiss pediatric heart centers and foreign donor procurement organizations. Of these, 26/136 (19%) organs were accepted and transplanted: 18 hearts were transplanted in Switzerland, and 13 of these were foreign. Reasons for refusal were (1) no compatible recipient due to blood group or weight mismatch, 89.4%; (2) medical, meaning organ too marginal for transplantation, 7.4%; (3) logistic, 1.4%; and (4) other, 1.8%. Five organs were refused in Switzerland by one center but later accepted and successfully transplanted by another center. Hearts from outside Switzerland were transplanted significantly less than Swiss hearts (n = 16/120 vs. 10/16, p < .001). Conclusion: The most common reason for refusing a pediatric donor heart is lack of compatibility with the recipient. Few hearts are refused for medical reasons. A more generous acceptance seems to be justified in selected patients. Switzerland receives a high number of foreign offers, but their rate of acceptance is lower than that of Swiss donations.

BackgroundDuring donation after circulatory death (DCD), cardiac grafts are exposed to potentially damaging conditions that can impact their quality and post-transplantation outcomes. In a clinical DCD setting, patients have closed chests in most cases, while many experimental models have used open-chest conditions. We therefore aimed to investigate and characterize differences in open- vs. closed-chest porcine models.MethodsWithdrawal of life-sustaining therapy (WLST) was simulated in anesthetized juvenile male pigs by stopping mechanical ventilation following the administration of a neuromuscular block. Functional warm ischemic time (fWIT) was defined to start when systolic arterial pressure was <50 mmHg. Hemodynamic changes and blood chemistry were analyzed. Two experimental groups were compared: (i) an open-chest group with sternotomy prior to WLST and (ii) a closed-chest group with sternotomy after fWIT.ResultsHemodynamic changes during the progression from WLST to fWIT were initiated by a rapid decline in blood oxygen saturation and a subsequent cardiovascular hyperdynamic (HD) period characterized by temporary elevations in heart rates and arterial pressures in both groups. Subsequently, heart rate and systolic arterial pressure decreased until fWIT was reached. Pigs in the open-chest group displayed a more rapid transition to the HD phase after WLST, with peak heart rate and peak rate-pressure product occurring significantly earlier. Furthermore, the HD phase duration tended to be shorter and less intense (lower peak rate-pressure product) in the open-chest group than in the closed-chest group.DiscussionProgression from WLST to fWIT was more rapid, and the hemodynamic changes tended to be less pronounced in the open-chest group than in the closed-chest group. Our findings support clear differences between open- and closed-chest models of DCD. Therefore, recommendations for clinical DCD protocols based on findings in open-chest models must be interpreted with care.

BACKGROUND:Heart transplantation with donation after circulatory death and ex-situ heart perfusion offers excellent outcomes and increased transplantation rates. However, improved graft evaluation techniques are required to ensure effective utilization of grafts. Therefore, we investigated circulating factors, both in-situ and ex-situ, as potential biomarkers for cardiac graft quality. METHODS:Circulatory death was simulated in anesthetized male pigs with warm ischemic durations of 0, 10, 20, or 30 minutes. Hearts were explanted and underwent ex-situ perfusion for 3 hours in an unloaded mode, followed by left ventricular loading for 1 hour, to evaluate cardiac recovery (outcomes). Multiple donor blood and ex-situ perfusate samples were used for biomarker evaluation with either standard biochemical techniques or nuclear magnetic resonance spectroscopy. RESULTS:Circulating adrenaline, both in the donor and at 10 minutes ex-situ heart perfusion, negatively correlated with cardiac recovery (p < 0.05 for all). We identified several new potential biomarkers for cardiac graft quality that can be measured rapidly and simultaneously with nuclear magnetic resonance spectroscopy. At multiple timepoints during unloaded ex-situ heart perfusion, perfusate levels of acetone, betaine, creatine, creatinine, fumarate, hypoxanthine, lactate, pyruvate and succinate (p < 0.05 for all) significantly correlated with outcomes; the optimal timepoint being 60 minutes. CONCLUSIONS:In heart donation after circulatory death, circulating adrenaline levels are valuable for cardiac graft evaluation. Nuclear magnetic resonance spectroscopy is of particular interest, as it measures multiple metabolites in a short timeframe. Improved biomarkers may allow more precision and therefore better support clinical decisions about transplantation suitability.

BACKGROUND:This study evaluated the hemodynamic performance of arterial and venous cannulae in a compliant pediatric extracorporeal membrane oxygenation (ECMO) mock circuit in pulsatile and non-pulsatile flow conditions. METHODS:The ECMO setup consisted of an oxygenator, diagonal pump, and standardized-length arterial/venous tubing with pressure transducers. A validated left-heart mock loop was adapted to simulate pediatric conditions. The pulsatile flow was driven by a computer-controlled piston pump set at 120 bpm. A roller pump was used for non-pulsatile conditions. The circuit was primed with 40% glycerol-based solution. The cardiac output was set to 1 L/min and the aortic pressure to 40-50 mmHg. Four arterial cannulae (8Fr, 10Fr, 12Fr, 14Fr) and five venous cannulae (12Fr, 14Fr, 16Fr, 18Fr, 20Fr) (Medtronic, Inc., Minneapolis, MN, USA) were tested at increasing flow rate in 12 combinations. RESULTS:The pulsatile condition required lower ECMO pump speeds for all cannulae combinations at a given flow rate, inducing a significantly smaller increase of flow in the mock loop. Under non-pulsatile conditions, the aortic and arterial pressures in the cannulae were higher (p < 0.01) while no significant differences in pressure drop and pressure-flow characteristics (M-number) were observed. The total hemodynamic energy was higher in case of non-pulsatile flow (p < 0.01). CONCLUSION:Under non-pulsatile conditions, the system was characterized by overall higher pressures, resulting in higher support to the patient. The consequent increase of potential energy compensates for increases of kinetic energy, leading to a higher total hemodynamic energy. Pressure gradients and M number are independent of the testing conditions. Pulsatile testing conditions led to more physiological testing conditions, and it is recommended for ECMO testing.

ObjectiveMinimally invasive extracorporeal circulation has been shown to be non-inferior or even superior to conventional cardiopulmonary bypass circuits in isolated coronary artery bypass grafting, but there is little evidence whether the addition of a heparin-coated circuit can further reduce the inflammatory response and amount of bleeding in these patients.MethodsA single-center randomized control trial enrolled 49 adult patients scheduled to undergo isolated coronary artery bypass grafting with minimally invasive extracorporeal circulation (MiECC) between January 2015 and December 2018. Patients were randomized 1:1 to either the heparin-coated circuit group, or the uncoated (control) circuit group. The primary outcome was chest tube output 18 h after weaning from MiECC, and secondary outcomes included inflammatory (TNF-α, IL-6, IL-8, IL-10) and complement (C3a, C4d, C5a, sC5b-9) biomarkers, platelet count and function (D2D, TAT, SDC1, PF4), number of transfused blood products, and 30-day survival.ResultsPatients were randomized to undergo myocardial revascularization using heparin-coated circuits (n = 25), and to the uncoated MiECC circuit (n = 24), with comparable baseline demographics. No significant difference was observed in chest tube output and for all secondary outcomes. IL-6 and IL-8 were increased from baseline at 18 h after weaning (effect size 0.29 and 0.05, respectively) and sC5b-9 was lower (effect size 0.11) in the heparin-coated than in the uncoated MiECC, although not significantly different.ConclusionsCompared with an uncoated MiECC circuit, heparin-coated MiECC circuit was not associated with a reduction in postoperative bleeding, transfusion, inflammation, complement activation, and platelet biomarkers, following isolated coronary artery bypass grafting.

OBJECTIVES This study aims to describe the outcomes of surgical correction for anomalous aortic origin of coronary artery (AAOCA) with regard to symptom relief.METHODS We performed a retrospective multicentre study including surgical patients who underwent correction for AAOCA between 2009 and 2022. Patients who underwent concomitant cardiac procedures were also included. However, to analyse symptom relief, we only assessed the subgroup of symptomatic patients who underwent isolated correction for AAOCA.RESULTS A total of 71 consecutive patients (median age 55, range 12-83) who underwent surgical correction for AAOCA were included in the study. Right-AAOCA was present in 56 patients (79%), left-AAOCA in 11 patients (15%) and single coronary ostium AAOCA in 4 patients (6%). Coronary unroofing was performed in 72% of the patients, coronary reimplantation in 28% and an additional neo-ostium patchplasty in 13% of the patients. In 39% of the patients, a concomitant cardiac procedure was performed. During follow-up, no cardiovascular-related death was observed. Three patients (4.2%) had a myocardial infarction and underwent postoperative coronary artery bypass grafting. Six patients (8.5%) needed postoperative temporary mechanical circulatory support. Among the 34 symptomatic patients who underwent isolated AAOCA correction, 70% were completely asymptomatic after surgery, 12% showed symptom improvement and no symptom improvement was observed in 18% of the patients (median follow-up 3.5 years, range 0.3-11.1).CONCLUSIONS Correction for AAOCA can be safely performed with or without concomitant cardiac procedures. Performing AAOCA correction leads to a significant improvement in symptoms for most patients.

We appreciate the article by Zaleski et al., as it described in detail the challenging management of a patient with hypoplastic left heart syndrome undergoing stage I palliation (S1P), one of the most demanding tasks in cardiac surgery and anesthesiology for congenital heart disease.1 The course of the young patient presented in their article was uneventful. Nonetheless, internationally reported premature mortality is high at up to 14.3%, and remains at 8%-to-11% even in high-volume North American centers, even after establishing specialized

Objectives: To compare the efficacy and clinical outcomes of transcatheter edge -to-edge mitral valve repair (TMVr) and surgical mitral valve repair (SMVr) among patients with secondary mitral regurgitation (SMR).Methods: Consecutive patients with SMR treated using either TMVr (n = 199) or SMVr (n = 222) at 2 centers were included and retrospectively analyzed. To account for differences in patient demographic characteristics, 1:1 propensity score match-ing was performed. The primary endpoint was all-cause death within 2 years after the procedure.Results: The study population consisted of 202 matched patients. At 2 years, all -cause mortality was 24.3% for TMVr and 23.0% for SMVr (hazard ratio, 0.97; 95% confidence interval, 0.55-1.71; P = .909). Severe heart failure symptoms at 2 years were less prevalent after SMVr (New York Heart Association functional class III or IV: 13.5% vs 29.5%; P = .032) than after TMVr. A higher proportion of the SMVr patients had SMR reduction to none or mild at discharge (90.8% vs 72.0%; P < .001) and 2 years (86.5% vs 59.6%; P < .001). Among patients who achieved none or mild MR at discharge, 7 patients (10.1%) in the SMVr group and 15 (34.9%) in the TMVr group had progression to moderate or greater MR at 2 years (P = .003). Left ventricular ejection fraction (LVEF) significantly improved (+10.1% +/- 11.1%; P <.001) after SMVr (LVEF at 2 years: 45.7% +/- 12.8%), whereas it remained unchanged (-1.3% +/- 8.9%; P = .260) after TMVr (LVEF at 2 years: 34.0% +/- 13.2%).Conclusions: In this propensity score-matched analysis, there was no significant difference in 2-year survival between TMVr and SMVr, despite greater and more du-rable SMR reduction, as well as LVEF improvement in the surgical group. (J Thorac Cardiovasc Surg 2023;165:2037-46)

metabolizing both glucose and lactate.The hearts that were transplanted displayed stable hemodynamics and good biventricular function.Conclusion: Neonatal and pediatric hearts can be safely perfused for an extended period of time at subnormothermic conditions in a blood-based perfusate.This approach could significantly enhance donor organ sharing by removing geographical and transportation barriers.Further work is required to determine the optimal perfusate composition and metabolic support.

Purpose: There is a paucity of evidence regarding lung transplantation (LT) in human immunodeficiency virus (HIV)-infected individuals.Methods: In this single-center retrospective chart review from 1/1/2018 to 9/30/2022, we evaluated rates of primary graft dysfunction (PGD), acute cellular rejection (ACR), pulmonary infections, HIV viral load (VL) recurrence, and mortality at 30, 90 days and 1 year in adult HIV-infected patients undergoing LT at Cedars-Sinai Medical Center.Results: We identified 6 HIV-infected LT recipients: 4 male and 2 female.Average age at LT was 60 years (range: 49-73y).Pre-transplant diagnoses included: nonspecific interstitial pneumonia (N=2), idiopathic pulmonary fibrosis (N= 2), chronic hypersensitivity pneumonitis (N=1), and pulmonary arterial hypertension (N=1).All patients were receiving antiretroviral therapy (ART).4 patients had an undetectable VL at baseline, 2 patients had VL below 100 copies/mL.Average CD4+ counts before LT was 219 cells/mL.5 patients received bilateral lung transplantation, while 1 patient received single lung transplantation.At 72 hours 3 LT recipients developed PGD grade 2 (50%), one developed PGD grade 3 (16%).5 LT recipients received tacrolimus, prednisone and mycophenolate mofetil as maintenance immunosuppression regimen, one recipient was on tacrolimus, prednisone and everolimus.3 recipients (50%) developed ACR grade 1 during first year after LT. 4 recipients (66%) developed clinically significant pulmonary bacterial and/or fungal infections based on broncho-alveolar lavage cultures.1 recipient developed a detectable HIV VL during first year after LT, which resolved with ART modification.No acquired immunodeficiency syndrome (AIDS)-defining illnesses were detected.Survival at 30 and 90 days was 100%. 1 year survival was 100% in 3 recipients eligible. Conclusion:We demonstrated encouraging clinical outcomes in 6 adult HIV-infected LT recipients including rates of PGD grade 3, ACR and infections.HIV VL was well controlled in all LT recipients.In conclusion, LT appears to be feasible and safe in patients with well controlled HIV infection.

BACKGROUND: Transvenous lead extraction (TLE) is the recommended management strategy for a variety of cardiac implantable electronic device (CIED) infections, malfunctions and other conditions.Large registries have established the safety and efficacy of TLE per se but temporal outcome data after the introduction of an institutional lead management programme remain scarce.OBJECTIVE: To investigate the impact of a structured institutional lead management programme on TLE outcomes.METHODS: All patients who underwent TLE at our institution between January 2013 and December 2020 were included.We assessed procedural outcomes after TLE for two separate time periods: from January 2013 to December 2018 and January 2019 to December 2020 (after introduction of a structured institutional lead management programme).RESULTS: In 2013-2018, the median number of TLE procedures per year at our centre was 14 (range 10-19, total 84).In 2019/2020, the median number of interventions per year increased to 46 (range 41-51, total 92).Noninfectious indications for TLE became more frequent (p <0.001), and the proportion of TLEs due to infections decreased.Median lead dwell time was not different (4.3 years [2013-2018] vs 4.4 years [2019-2020], p = 0.43).Clinical success rates improved from 90% to 98% (p = 0.020) and complete procedural success increased from 85% to 95% (p = 0.027).There was a trend towards a lower number of TLE-associated complications (p = 0.07).CONCLUSION: A structured institutional lead management programme and increasing experience significantly improve TLE outcomes.TLE can be safely performed in high-volume centres, allowing for a more liberal extraction policy, including in the case of non-infectious TLE indications.