Female sex as an independent predictor of major complications during transvenous lead extraction

BACKGROUND Transvenous lead extraction (TLE) is increasingly performed, and accurate procedural risk assessment is essential. Female sex has been reported as a possible risk factor for major complications, but previous analyses rarely balanced procedural and clinical characteristics between sexes, leaving unclear whether the association reflects sex itself or greater anatomical-procedural susceptibility. OBJECTIVE To assess whether female sex remains independently associated with major complications during TLE after extensive propensity-score balancing of clinical and procedural confounders. METHODS We retrospectively analyzed 4290 patients undergoing non-laser TLE at three high-volume centers by one primary operator (2006-2024). Women were matched 1:1 to men on ten clinical and procedural covariates. Major complications (HRS/EHRA criteria) were the prespecified primary endpoint. Multivariable logistic regression including female sex and all matching covariates was performed; Kaplan-Meier and Cox mortality analyses were secondary and exploratory. RESULTS After matching, 1197 women and 1197 men were well balanced. Despite comparable procedural complexity, major complications were more frequent in women (3.76% vs 1.50%; p<0.001), including hemopericardium (2.54% vs 0.75%; p=0.001) and rescue cardiac surgery (2.17% vs 0.75%; p=0.006); procedural success was similar. Female sex remained independently associated with major complications (OR 2.72, 95% CI 1.52-4.85; p<0.001), as did longer lead dwell time (OR 1.12 per year; p<0.001); higher hemoglobin was protective (OR 0.86 per g/dl; p=0.026). CONCLUSION After extensive balancing of confounders, female sex remained independently associated with major complications during TLE, supporting further investigation of sex-related procedural vulnerability and refinement of TLE risk models.