Use of Transesophageal Echocardiography to Improve the Safety of Transvenous Lead Extraction

Objectives The aim of this study was to evaluate the utility of transesophageal echocardiography (TEE) during transvenous lead extraction (TLE) involving both conventional and laser lead removal. Background TLE carries a small but measurable risk of serious adverse events. Few studies have examined the potential benefit of continuous monitoring with TEE during this procedure. Methods Continuous TEE monitoring was performed in 100 consecutive patients (67% male; average age, 57 ± 17 years) who underwent TLE in the past 5 years. Lead extraction was attempted for 193 leads. The average time since lead implant was 78 ± 55 months (range, 1.4 to 274.4 months). Indications for extraction were device endocarditis (n = 28), lead fracture (n = 28), recalled lead (n = 21), pocket infection (n = 17), and other (n = 6). Results Complete success occurred in 181 leads (94%), partial success in 4 leads (2%), and failure in 8 leads (4%). Eighty patients required laser lead extraction (80%). Major complications included 1 right ventricular and 2 right atrial/superior vena cava lacerations, which were detected and localized within 1 to 2 min with the use of TEE and resulted in prompt surgical repair. There was 1 upper gastrointestinal bleed caused by the TEE probe. TEE prevented premature termination and unnecessary surgery in 4 patients with hypotension but no intracardiac abnormalities seen on TEE. In-hospital mortality rate was 0%. In total, TEE provided immediately useful clinical information in 7 patients (7%). Conclusions Continuous monitoring with TEE facilitates prompt diagnosis and treatment of intracardiac damage and prevents premature termination of cases with hypotension but no abnormalities on TEE.