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

Background 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 these procedures. Objective This study aims to assess the feasibility and safety of performing TLE without periprocedural TEE monitoring, utilizing venous venography when necessary. Methods We conducted a retrospective analysis of all patients who underwent TLE in our clinic between July 2019 and January 2025. 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, and a transthoracic echocardiography was performed at the end of each procedure. Results A total of 179 patients (mean age: 69.8 ± 13 years; 29.2% female, BMI: 28.3 ± 7) underwent TLE. Implantable defibrillator cardioverters (ICD) were present in 112 patients (62.6%, VVI – 30.4%, DDD – 26.7%, CRT – ICD 42.9%) and permanent pacemakers (PPM) in 67 patients (37.4%, VVI – 10.5%, DDD – 71.6%, CRT– PM 13.4%, CCM 4.5%). The total number of leads was 376, including 125 ICD leads and 251 PPM leads. Of those, 9.8% (n = 37) were abandoned leads. The number of extracted leads was 283 (75.3%), and the mean lead dwell time was 93.6 months. Indications for TLE included local infection (n=35, 19.6%), systemic infection (n=51, 28.5%), lead dysfunction (n=65, 36.3%), and other reasons (n=28, 15.6%). The mean laser treatment and fluoroscopy times were 51.2 ± 50.4 and 1658.7 ± 9301.5 seconds, respectively. Venous venography was performed in 12 cases due to unusual hemodynamic changes to assess vascular or cardiac tears. Three complications were reported (1.7%): one vascular tear at the upper SVC requiring sternotomy, one cardiac tamponade requiring pericardiocentesis, and one death caused by low cardiac output with no findings of reversible causes. In all the cases, TEE was used as a secondary tool for cardiac diagnosis. Conclusion TLE without periprocedural TEE monitoring is a feasible and safe approach. Hemodynamic monitoring via arterial access, combined with intraoperative venography using femoral venous sheaths, can help assess and localize complications, facilitating appropriate management.