Impact of patent foramen ovale on transvenous lead extraction characteristics and outcomes

Background Transvenous lead extraction (TLE) may be indicated for cardiac implantable electronic device infection, malfunction, or upgrade. TLE can increase right heart pressures and mobilize debris, resulting in a right-to-left embolism and stroke via a patent foramen ovale (PFO). Objective To identify the prevalence of PFO in patients undergoing TLE and compare incidence of adverse events. Methods Intraoperative transesophageal echocardiogram (TEE) is routinely performed during TLE at University of California, San Diego to identify PFO. Between 6/2020 and 10/2025, 283 patients underwent 289 lead extraction procedures and had intraoperative TEE reports available. Patients were compared by PFO status. Results Of 283 patients, mean age was 64.98 (standard deviation ± 15.17); 65.74% were male. PFO was detected in 37 (12.80%) patients but was not associated with different baseline characteristics. Overall, mean lead count was 2.14 ± 0.51, dwell time was 4.91 ± 4.25 years, and procedural success was 90.66% (OR 0.43, 95% CI 0.16-1.19, p=0.106). Most common extraction indications were malfunction (45.67%) and infection (30.45%). Primary endpoints were in-hospital stroke (1/37 (2.7%) in PFO cohort vs 1/252 (0.40%), OR 3.81, 95% CI 0.18-79.38, p=0.388), myocardial infarction (none in either cohort), and all-cause mortality (2/37 (5.41%) in PFO cohort vs 0/252 (0%) in no PFO cohort, Fisher's exact test p=0.016, unable to calculate OR with multivariate regression). Of these two deaths in the PFO cohort, one was due to stroke-related complications and the other to sepsis. Conclusion Stroke incidence was not significantly different by PFO status, but mortality was significantly higher in those with PFO.