Leadless pacemakers are a valuable adjunct for treating selected patients requiring single-chamber pacing. However, in this initial experience, major complication rates were high (9.8%). The implant procedure requires proper training and should be performed in an adequate setting.

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We have read with much attention the initial Swiss experience with the Micra transcatheter pacing system. 1 Notably, Valiton et al. report a rather high 9.8% rate of complications, which occurred in a series of 92 patients implanted in four different centres in Switzerland. As stated in the discussion, this rate of major complications is more than twice higher than previously reported. 2,3 We do agree that this technology can be harmful and that training remains crucial.In our own experience in Tours, France, a total of 145 Micra TPS devices have been implanted by the same physician as main operator between July 2015 and September 2018, i.e. 3.8 devices implanted per month. In this aged population (mean 80 ± 10, median 82 years), we report three perioperative complications: two cardiac tamponades, one leading to post-operative death; one groin arteriovenous fistula, requiring vascular repair. We also report two complications during follow-up: one early threshold elevation requiring extraction and reimplantation of a new Micra system at 1 week; one late threshold elevation requiring implantation of a 2nd system at 30 months. Interestingly, the rate of complications dropped from 11.4% after 35 cases to 3.4% after 145 cases. The implantation success rate also increased from 80% after the 10 initial cases to 100% for the 135 following procedures.Taking into account the relatively low rates of Micra TPS implantations per-centre, and the potential severe complications, we think that most implantations should be preferably performed by the same well-trained operators, even in relatively high-volume centres.

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