The Regionalization of High‐Volume Cardiac Pacing: A Prospective Cohort Study on Safety, Feasibility, and the Learning Curve in a Geriatric Population

Figures

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  Figure 1. Evolution of procedural efficiency across the surgical learning curve. The graph demonstrates the relationship between cumulative case volume (x‐axis) and total procedure time in minutes (y‐axis). The overall learning curve is demarcated into three distinct clinical phases: the initial Acquisition phase (Cases 1–57; mean time 120 min), the Stabilization phase (Cases 58–115; mean time 85 min), and the final Expertise phase (Cases 116–173; mean time 78 min). The trendline illustrates a continuous reduction in procedural duration, highlighting that optimal surgical efficiency is consistently achieved and stabilized after approximately 100 cases. Figure 1: Learning Curve (Time vs. Case Number).

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  Figure 2. Cumulative Sum (CUSUM) safety analysis of major procedure‐related complications. This CUSUM curve tracks the cumulative incidence of major complications across the 173 consecutive pacemaker implantations. The slope of the curve represents the complication rate at a given stage of the programme's maturity. A steeper slope is observed during Phase 1 (Acquisition, 8.7% rate), reflecting early procedural adjustments. The curve visibly flattens through Phase 2 (Stabilization, 5.2% rate) and reaches a sustained safety plateau in Phase 3 (Expertise), where the major complication rate drops to 3.4%. The embedded bar chart highlights the statistically significant reduction in major complications between the initial and expert phases (p < 0.05). Figure 2: CUSUM Safety Curve (Complications vs. Case Number).

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  Figure 3. Benchmarking of clinical safety and procedural outcomes against European Heart Rhythm Association (EHRA) averages. (A) The major complication rate of the regional centre during its mature Expertise Phase (n = 116) compared to the established EHRA registry average. The regional programme demonstrated a significantly lower complication rate (3.4% vs. 7.8%; p < 0.05). (B) Procedural and radiation safety metrics, illustrating the centre's exceptionally low mean fluoroscopy time (3.9 min) compared to typical Western European benchmarks. (C) Intraoperative electrical stability (mean R‐wave sensing amplitude and ventricular pacing threshold), confirming that the regional centre achieves optimal, non‐inferior lead performance parameters. Figure 3: Benchmarking Bar Chart (Our Centre vs. EHRA Averages).