Assessing the role of transesophageal echocardiography in transvenous lead extraction: is it still essential?

During transvenous lead extraction (TLE), transesophageal echocardiography (TEE) is commonly used to detect cardiac complications. However, pleural complications cannot be recognized early. The use of intraoperative venography, hemodynamic monitoring via arterial access, and femoral sheaths may make TEE superfluous during such procedures.

The purpose of this study was to assess the feasibility and safety of performing TLE without periprocedural TEE monitoring, using venous venography when necessary.

We conducted a retrospective analysis of all patients who underwent TLE in our clinic between July 2019 and January 2024. Laser sheaths were used as the primary extraction tool. All procedures were performed under general anesthesia with continuous invasive arterial blood pressure monitoring. In all cases, a pigtail catheter was placed via venous femoral sheaths. A transthoracic echocardiography was performed at the end of each procedure.

A total of 150 patients (mean age: 69.8 ± 12.6 years; 28.7% female) underwent TLE. The total number of leads was 340, comprising 143 ICD leads and 197 pacemaker leads. Of these, 274 leads were extracted. Indications for TLE included local infection (n=28,18.7%), systemic infection (n=43, 28.7%), lead dysfunction (n=56, 37.3%), and other reasons (n=23, 15.3%). The mean lead dwell time was 98.2 months. Venous venography was performed in 11 cases due to unusual hemodynamic changes to assess or exclude vascular or cardiac tears. Two complications (1.3%) were reported: one vascular tear at the upper SVC requiring sternotomy and one cardiac tamponade requiring pericardiocentesis.

TLE without periprocedural TEE monitoring is feasible and safe. Hemodynamic monitoring via arterial access, combined with intraoperative venography using venous femoral sheaths, can help assess complications, localize them, and facilitate appropriate complication management.