The role of transesophageal echocardiography in predicting technical problems and complications of transvenous lead extractions procedures

BACKGROUND: Transesophageal echocardiography (TEE) is a useful tool in preoperative evaluation of patients undergoing transvenous lead extraction (TLE). HYPOTHESIS: Echocardiographic phenomena may determine the difficulty and safety of the procedure. METHODS: Data from 936 transesophageal examinations (TEE) performed at a high volume center in patients awaiting TLE from 2015 to 2019 were assessed. RESULTS: TEE revealed a total of 1156 phenomena associated with the implanted leads in 697 (64.85%) patients, including: asymptomatic masses on endocardial leads (AMEL) (58.65%), vegetations (12,73%), fibrous tissue binding the lead to the vein or heart wall (33.76%), lead-to-lead binding sites (18.38%), excess lead loops (19.34%), intramural penetration of the lead tip (16.13%) and lead-dependent tricuspid dysfunction (LDTD) (6.41%). Risk factors for technical difficulties during TLE in multivariate analysis were: fibrous tissue binding the lead to atrial wall (OR = 1.738; p < 0.05), to right ventricular wall (OR = 2.167; p < 0.001), lead-to-lead binding sites (OR = 1.628; p < 0.01) and excess lead loops (OR = 1.488; p < 0.05). Lead-to-lead binding sites increased probability of major complications (OR = 3.034; p < 0.05). Presence of fibrous tissue binding the lead to the superior vena cava (OR = 0.296; p < 0.05), right atrial wall (OR = 323; p < 0.05) and right ventricular wall (OR = 0.297; p < 0.05) reduced the probability of complete procedural success, whereas fibrous tissue binding the lead to the tricuspid apparatus decreased the probability of clinical success (OR = 0.307; p < 0.05). CONCLUSIONS: Careful preoperative TEE evaluation of the consequences of extended lead implant duration (enhanced fibrotic response) increases the probability of predicting the level of difficulty of TLE procedures, their efficacy and risk of major complications.