Leads with the Cut Proximal Ends Migrated into the Heart and Vasculature: A Rare Phenomenon among 3847 Lead Extraction Procedures.

Background: The study aimed to describe the phenomenon of leads migrated (MPLE) into the cardiovascular system (CVS). Methods: Retrospective analysis of 3847 transvenous lead extractions (TLE). Results: Over a 17-year period, 72 (1.87%) MPLEs (median dwell time 137.5 months) were extracted, which included mainly ventricular leads (56.94%). Overall, 68.06% of MPLEs had their cut proximal ends in the venous system. Most of them were pacing (95.83%) and passive fixation (98.61%) leads. Independent risk factors for MPLE included abandoned leads (OR = 8.473; p < 0.001) and leads located on both sides of the chest (2.981; p = 0.045). The higher NYHA class lowered the probability of MPLE (OR = 0.380; p < 0.001). Procedure complexity was higher in the MPLE group (procedure duration, unexpected procedure difficulties, use of additional (advanced) tools and alternative venous approach). There were no more major complications in the MPLE group, but the rate of procedural success was lower due to more frequent retention of non-removable lead fragments. Extraction of MPLEs did not influence long-term survival. Conclusions: 1. Extraction of leads with MPLE is rare among other TLE procedures (1.9%), 2. risk factors include abandoned leads and presence of leads on both sides of the chest but a higher NYHA class lowers the probability of MPLE, 3. complexity of MPLE extraction is higher regarding procedure duration, unexpected procedure difficulties, use of advanced tools and techniques but rates of major complications are comparable, and 4. extraction of MPLEs did not influence long-term survival.

Analysis of 1051 ICD Leads Extractions in Search of Factors Affecting Procedure Difficulty and Complications: Number of Coils, Tip Fixation and Position-Does It Matter?

Background: Implantable cardioverter-defibrillator (ICD) leads are considered a risk factor for major complications (MC) during transvenous lead extraction (TLE). Methods: We analyzed 3878 TLE procedures (including 1051 ICD lead extractions). Results: In patients with ICD lead removal, implant duration was almost half as long (69.69 vs. 114.0 months; p < 0.001), procedure complexity (duration of dilatation of all extracted leads, use of more advanced tools or additional venous access) (15.13% vs. 20.78%; p < 0.001) and MC (0.67% vs. 2.62%; p < 0.001) were significantly lower as compared to patients with pacing lead extraction. The procedural success rate was higher in these patients (98.29% vs. 94.04%; p < 0.001). Extraction of two or more ICD leads or additional superior vena cava (SVC) coil significantly prolonged procedure time, increased procedure complexity and use of auxiliary or advanced tools but did not influence the rate of MC. The type of ICD lead fixation and tip position did not affect TLE complexity, complications and clinical success although passive fixation reduces the likelihood of procedural success (OR = 0.297; p = 0.011). Multivariable regression analysis showed that ICD lead implant duration ≥120 months (OR = 2.956; p < 0.001) and the number of coils in targeted ICD lead(s) (OR = 2.123; p = 0.003) but not passive-fixation ICD leads (1.361; p = 0.149) or single coil ICD leads (OR = 1.540; p = 0.177) were predictors of higher procedure complexity, but had no influence on MC or clinical and procedural success. ICD lead implant duration was of crucial importance, similar to the number of leads. Lead dwell time >10 years is associated with a high level of procedure difficulty and complexity but not with MC and procedure-related deaths. Conclusions: The main factors affecting the transvenous removal of ICD leads are implant duration and the number of targeted ICD leads. Dual coil and passive fixation ICD leads are a bit more difficult to extract whereas fixation mechanism and tip position play a much less dominant role.

Lead Break during Extraction: Predisposing Factors and Impact on Procedure Complexity and Outcome: Analysis of 3825 Procedures.

Background: Currently, there are no reports describing lead break (LB) during transvenous lead extraction (TLE). Methods: This study conducted a retrospective analysis of 3825 consecutive TLEs using mechanical sheaths. Results: Fracture of the lead, defined as LB, with a long lead fragment (LF) occurred in 2.48%, LB with a short LF in 1.20%, LB with the tip of the lead in 1.78%, and LB with loss of a free-floating LF in 0.57% of cases. In total, extractions with LB occurred in 6.04% of the cases studied. In cases in which the lead remnant comprises more than the tip only, there was a 50.31% chance of removing the lead fragment in its entirety and an 18.41% chance of significantly reducing its length (to less than 4 cm). Risk factors for LB are similar to those for major complications and increased procedure complexity, including long lead dwell time [OR = 1.018], a higher LV ejection fraction, multiple previous CIED-related procedures, and the extraction of passive fixation leads. The LECOM and LED scores also exhibit a high predictive value. All forms of LB were associated with increased procedure complexity and major complications (9.96 vs. 1.53%). There was no incidence of procedure-related death among such patients, and LB did not affect the survival statistics after TLE. Conclusions: LB during TLE occurs in 6.04% of procedures, and this predictable difficulty increases procedure complexity and the risk of major complications. Thus, the possibility of LB should be taken into account when planning the lead extraction strategy and its associated training.

Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices.

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

VDD Lead Extraction-Differences with Other Leads and Practical Tips in Management.

Background: VDD (atrial sensing, ventricular sensing/pacing) leads are relatively rarely implanted; therefore, experience in their extraction is very limited. We aimed to investigate whether VDD lead removal may be a risk factor for the increased complexity of transvenous lead extraction (TLE) or major complications. Methods: We retrospectively analyzed 3808 TLE procedures (including 103 patients with VDD leads). Results: If TLE included VDD lead removal, procedure duration (lead dilation time) was prolonged, complicated extractions were slightly more common, and more advanced tools were required. This is partly due to longer implant duration (in patients with VDD systems-135.2 months; systems without VDD leads-109.3 months; p < 0.001), more frequent presence of abandoned leads (all systems containing VDD leads-22.33% and all systems without VDD leads-10.77%), and partly to the younger age of patients with VDD leads (51.74 vs. 57.72 years; p < 0.001, in the remaining patients) at the time of system implantation. VDD lead extraction does not increase the risk of major complications (1.94 vs. 2.34%; p = 0.905). Conclusions: The extraction of VDD leads may be considered a risk factor for increased procedure complexity, but not for major complications. However, this is not a direct result of VDD lead extraction but specific characteristics of the patients with VDD leads. Operator skill and team experience combined with special custom maneuvers can enable favorable results to be achieved despite the specific design of VDD leads, even with older VDD lead models.

How does a CIED presence influence chances and safety of haemodialysis access? Conclusions from over 3000 thoracic venografies.

Patients requiring temporal or permanent catheter or arterio-venous fistula (AVF) for haemodialysis may be in challenging situation, if they are cardiovascular implantable electronic devices (CIED) carriers. MATERIALS AND METHODS: The authors analysed preoperative venogrphies of 3100 patients referred for transvenous lead extraction for a possible chance of safe haemodialysis catheter (HC) implantation or proper AVF function. RESULTS: A chance of safe catheter implantation parallel to existing leads reaches 68.8% ipsilaterally to CIED. Contraindications for implantation have been found in less than 2% of cases contralaterally. Ipsilaterally proper AVF function chance has been found in 50.3% of the cases and almost 98% contralaterally. A bilateral chest electrodes location require the special attention. Abandoned lead, lead burden, bilateral leads, additional lead implantation or abandonment, and implant duration may have a significant influence on HC insertion or proper function of arteriovenous fistula. CONCLUSION: (1) Obstruction of prominent thoracic veins is a frequent finding in CIED carriers and may impede or disable implantation haemodialysis accesses. (2) Implantation of temporary or permanent HC may be questionable ipsilaterally to the CIED in 31.2% and contralaterally in 2.0% of patients. Proper function of AVF is uncertain in 49.7% ipsilaterally and 2.1% contralaterally to CIED. (3) Pacing history and leads dwell time influence chances of success haemodialysis access even on the free-from CIED chest side. (4) Proper venous flow evaluation seems to be valuable in CIED carriers before an attempt of haemodialysis access formation, even contralaterally.

Transvenous Lead Extraction in Pediatric Patients　- Is It the Same Procedure in Children as in Adults?

BACKGROUND: Cardiac implantable electronic devices (CIED) are very rare in the pediatric population. In children with CIED, transvenous lead extraction (TLE) is often necessary. The course and effects of TLE in children are different than in adults. Thus, this study determined the differences and specific characteristics of TLE in children vs. adults.Methods and Results: A post hoc analysis of TLE data in 63 children (age ≤18 years) and 2,659 adults (age ≥40 years) was performed. The 2 groups were compared with respect to risk factors, procedure complexity, and effectiveness. In children, the predominant pacing mode was a single chamber ventricular system and lead dysfunction was the main indication for lead extraction. The mean implant duration before TLE was longer in children (P=0.03), but the dwell time of the oldest extracted lead did not differ significantly between adults and children. The duration (P=0.006) and mean extraction time per lead (P<0.001) were longer in children, with more technical difficulties during TLE in the pediatric group (P<0.001). Major complications were more common, albeit not significantly, in children. Complete radiographic and procedural success were significantly lower in children (P<0.001). CONCLUSIONS: TLE in children is frequently more complex, time consuming, and arduous, and procedural success is more often lower. This is related to the formation of strong fibrous tissue surrounding the leads in pediatric patients.

Pacemaker leads as a potential source of problems in patients who might need a central venous access port.

Background: Lead-dependent venous occlusion may impede the insertion of a central venous access device (CVAD). The aim of this retrospective, cohort study was to assess the chance of implantation of CVAD in patients with cardiac implantable electronic devices (CIEDs). Methods: We reviewed and analyzed 3,075 venograms of patients with CIEDs undergoing transvenous lead extraction (TLE) between June 2008 and July 2021. Relationship between venous patency and the chance of CVAD placement was estimated. Results: In 2,318 (75.38%) patients, venography showed no potential obstacles to venous port implantation on the ipsilateral side. In patients with leads on the left side, significant narrowing more often affected the subclavian vein than the brachiocephalic vein [1,595 (55.29%) vs. 830 (28.63%), respectively] or the superior vena cava (SVC) [21 (0.73%) cases]. Furthermore, the subclavian and brachiocephalic veins on the opposite side were also narrowed [35 (2.35%) and 27 (1.24%), respectively]. The chances of port insertion were assessed as easy on CIED side or opposite side in 2,318 (75.38%) and 2,291 (97.91%) patients, respectively), as difficult insertion/questionable performance in 246 (8.00%) and 22 (0.94% patients) and doubtful or impossible insertion/questionable performance in 511 (16.62%)/27 (1.15%) patients with CIED. Conclusions: (I) Varying degrees of lead-dependent venous obstruction (LDVO) is a frequent finding in patients with CIEDs; (II) the major thoracic veins on the opposite side of the chest may also be significantly narrowed; (III) venography should be considered before attempted CVAD insertion in patients with long lead dwell times or in patients after CIED removal, including planned contralateral port placement.

"Ghost", a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance.

"Ghosts" are fibrinous remnants that become visible during transvenous lead extraction (TLE). METHODS: Data from transoesophageal echocardiography-guided TLE procedures performed in 1103 patients were analysed to identify predisposing risk factors for the development of so-called disappearing ghosts-flying ghosts (FG), or attached to the cardiovascular wall-stable ghosts (SG), and to find out whether the presence of ghosts affected patient prognosis after TLE. RESULTS: Ghosts were detected in 44.67% of patients (FG 15.5%, SG 29.2%). The occurrence of ghosts was associated with patient age at first system implantation [FG (OR = 0.984; p = 0.019), SG (OR = 0.989; p = 0.030)], scar tissue around the lead (s) [FG (OR = 7.106; p < 0.001, OR = 1.372; p = 0.011), SG (OR = 1.940; p < 0.001)], adherence of the lead to the cardiovascular wall [FG (OR = 0.517; p = 0.034)] and the number of leads [SG (OR = 1.450; p < 0.002). The presence of ghosts had no impact on long-term survival after TLE in the whole study group [FG HR = 0.927, 95% CI (0.742-1.159); p = 0.505; SG HR = 0.845, 95% CI (0.638-1.132); p = 0.265]. CONCLUSIONS: The degree of growth and maturation of scar tissue surrounding the lead was the strongest factor leading to the development of both types of ghosts. The presence of either form of ghost did not affect long-term survival even after TLE indicated for infection.

Cardiac tamponade as an inherent but potentially nonfatal complication of transvenous lead extraction: Experience with 1126 procedures performed using mechanical tools.

INTRODUCTION: Cardiac tamponade (CT) is one of the most common and dangerous complications of transvenous lead extraction (TLE). So far, however, there has been little discussion about the problem. METHODS: We analyzed the occurrence of CT in a group of 1226 patients undergoing TLE at a single reference center between June, 2015 and February, 2021. Using standard mechanical devices as first-line tools, a total of 2092 leads had been extracted. RESULTS: CT occurred in 18 patients (1.47%): due to injury to the wall of the right atrium in 14 patients (1.14%) and other cardiac walls in four patients (0.33%). Younger patient age at first implantation, female gender, high left ventricular ejection fraction (LVEF), lower New York Heart Association class, low Charlson comorbidity index, longer implant duration, and the number of previous procedures related to cardiac implantable electronic devices (CIED) are important patient-related risk factors for CT. Significant procedure-related risk factors include the number of extracted leads, extraction of atrial leads and longer dwell time of extracted leads. Intraoperative transoesophageal echocardiography (TEE) provides a lot of information about pulling on various cardiac structures and is able to detect a very early phase of bleeding to the pericardial sac. As a result of implementing best practices guidance in performing extraction procedures and close collaboration with cardiac surgeons that allowed immediate rescue intervention in our series of 18 CT cases, there were no procedure-related deaths (mortality 0%). CONCLUSIONS: The need for rescue surgery due to CT has no influence on clinical and procedural success. Early diagnosed (TEE monitoring) and properly managed CT does not generate any additional risk in short- and long-term follow-up after TLE.

Severity and Extent of Lead-Related Venous Obstruction in More Than 3000 Patients Undergoing Transvenous Lead Extraction.

Background: Lead-related venous stenosis/obstruction (LRVSO) may be a major challenge in patients with cardiac implantable electronic devices (CIED) when device upgrade, insertion of central lines, or creation of an arteriovenous fistula for hemodialysis is indicated. The aim of this study was to evaluate the extent and severity of LRVSO. Methods: We performed a retrospective analysis of 3002 venograms from patients awaiting transvenous lead extraction (TLE) to assess the occurrence, severity, and extent of LRVSO. Results: Mild LRVSO occurred in 19.9%, moderate in 20.7%, severe in 19.9% and total venous occlusion in 22.5% of the patients. Moderate/severe stenosis or total occlusion of the subclavian and brachiocephalic veins was found in 38.2% and 22.5% of the patients, respectively. LRSVO was not detected in 16.9% of the patients. Moderate and severe superior vena cava (SVC) obstruction and total SVC occlusion were rare (0.4%, 0.3%, and 0.3%, respectively). Lead insertion on the left side of the chest contributed to an increased risk of LRVSO compared to right-sided implantation. Major thoracic veins on the opposite side may be narrowed in varying degrees. Conclusion: A total of 60% of the patients with pacemaker or high-voltage leads have an advanced form of LRVSO. Any attempt to insert new pacing leads, central lines, venous ports, or catheters for hemodialysis, or to create dialysis fistula on the same side as the existing lead should be preceded by venography. Furthermore, venography may provide useful information, if it is planned to implant the lead or the catheter on the opposite side of the chest.

Disparities in transvenous lead extraction in young adults.

Adults with cardiac implantable electronic devices (CIEDs) implanted at an early age constitute a specific group of patients undergoing transvenous lead extraction (TLE). The aim of this study is to assess safety and effectiveness of TLE in young adults. A comparative analysis of two groups of patients undergoing transvenous lead extraction was performed: 126 adults who were 19-29 years old at their first CIED implantation (early adulthood) and 2659 adults who were > 40 years of age at first CIED implantation and < 80 years of age at the time of TLE (middle-age/older adulthood). CIED-dependent risk factors were more common in young adults, especially longer implant duration (169.7 vs. 94.0 months). Moreover younger age of patients at first implantation, regardless of the dwell lead time, is a factor contributing to the greater development of connective tissue proliferation on the leads (OR 2.587; p < 0.001) and adhesions of the leads with the heart structures (OR 3.322; p < 0.001), which translates into worse TLE results in this group of patients. The complexity of procedures and major complications were more common in younger group (7.1 vs. 2.0%; p < 0.001), including hemopericardium (4.8 vs 1.3; p = 0.006) and TLE-induced tricuspid valve damage (3.2 vs.0.3%; p < 0.001). Among middle-aged/older adults, there were 7 periprocedural deaths: 6 related to the TLE procedure and one associated with indications for lead removal. No fatal complications of TLE were reported in young adults despite the above-mentioned differences (periprocedural mortality rate was comparable in study groups 0.3% vs 0.0%; p = 0.739). Predictors of TLE-associated major complications and procedure complexity were more likely in young adults compared with patients aged > 40 to < 80 years. In younger aged patients prolonged extraction duration and higher procedure complexity were combined with a greater need for second line tools. Both major and minor complications were more frequent in young adults, with hemopericardium and tricuspid valve damage being predominant.

Safety and Effectiveness of Transvenous Lead Extraction in Patients with Infected Cardiac Resynchronization Therapy Devices; Is It More Risky than Extraction of Other Systems?

Background: Transvenous lead extraction (TLE) in patients with implantable cardioverter defibrillator (ICD) and cardiac resynchronization therapy (CRT) devices is considered as more risky. The aim of this study was to assess the safety and effectiveness of TLE in patients with infected CRT systems. Methods: Data of 3468 patients undergoing TLE in a single high-volume center in years 2006−2021 were analyzed. The clinical and procedural parameters as well as the efficacy and safety of TLE were compared between patients with infected CRT and pacemakers (PM) and ICD systems. Results: Infectious indications for TLE occurred in 1138 patients, including 150 infected CRT (112 CRT-D and 38 CRT-P). The general health condition of CRT patients was worse with higher Charlson's comorbidity index. The number of extracted leads was higher in the CRT group, but implant duration was significantly longer in the PM than in the ICD and CRT groups (98.93 vs. 55.26 vs. 55.43 months p < 0.01). The procedure was longer in duration, more difficult, and more complex in patients with pacemakers than in those in the CRT group. The occurrence of major complications and clinical and procedural success as well as procedure-related death did not show any relationship to the type of CIED device. Mortality at more than one-year follow-up after TLE was significantly higher among patients with CRT devices (22.7% vs. 8.7%) than among those in the PM group. Conclusion: Despite the greater burden of lead and comorbidities, the complexity and efficiency of removing infected CRT systems is no more dangerous than removing other infected systems. The duration of the implant seems to play a dominant role.

Efficacy and Safety of Transvenous Lead Extraction at the Time of Upgrade from Pacemakers to Cardioverter-Defibrillators and Cardiac Resynchronization Therapy.

BACKGROUND: Upgrading from pacemakers to ICDs and CRTs is a difficult procedure, and often, transvenous lead extraction (TLE) is necessary for venous access. TLE is considered riskier in patients with multiple diseases. We aimed to assess the complexity, risk, and outcome of TLE among CRT and ICD candidates. METHODS: We analyzed clinical data from 2408 patients undergoing TLE between 2006 and 2021. There were 138 patients upgraded to CRT-D, 33 patients upgraded to CRT-P and 89 individuals upgraded to ICD versus 2148 patients undergoing TLE for other non-infectious indications. RESULTS: The need for an upgrade was the leading indication for TLE in only 36-66% of patients. In 42.0-57.6% of patients, the upgrade procedure could be successfully done only after reestablishing access to the occluded vein. All leads were extracted in 68.1-76.4% of patients, functional leads were retained in 20.2-31.9%, non-functional leads were left in place in 0.0-1.1%, and non-functional superfluous leads were extracted in 3.6-8.4%. The long-term survival rate of patients in the CRT-upgrade group was lower (63.8%) than in the non-upgrade group (75.2%). CONCLUSIONS: Upgrading a patient from an existing pacemaker to an ICD/CRT is feasible in 100% of cases, provided that TLE is performed for venous access. Major complications of TLE at the time of device upgrade are rare and, if present do not result in death.

Risk Factors for Lead-Related Venous Obstruction: A Study of 2909 Candidates for Lead Extraction.

BACKGROUND: our knowledge of lead-related venous stenosis/occlusion (LRVSO) remains limited and there is still controversy regarding the risk factors for LRVSO. Venography is mandatory before transvenous lead extraction (TLE). METHODS: we performed a retrospective analysis of venograms in 2909 patients (39.43% females, average age 66.90 years) who underwent TLE between 2008 and 2021 at high-volume centers. RESULTS: the severity of LRVSO was likely to be dependent on the number of leads in the system (OR = 1.345; p = 0.003), the number of abandoned leads (OR = 1.965; p < 0.001), the presence of coronary sinus leads (OR = 1.184; p = 0.056), male gender (OR = 1.349; p = 0.003) and patient age at first CIED implantation (OR = 1.008; p = 0.021). The presence of permanent atrial fibrillation (OR = 0.666; p < 0.001) and right ventricular diastolic diameter (OR = 0.978; p = 0.006) showed an inverse correlation with the degree of LRVSO. The combined three-model multivariate analysis provided better prediction of LRSVO using the above-mentioned factors than the CHA2DS2-VASc score. CONCLUSIONS: the severity of LRVSO is probably dependent on the mechanical impact of the implanted/abandoned leads on the vein wall, therefore the study has demonstrated the central role of system-/procedure-related risk factors. The thrombotic mechanism may be less important, especially long after implantation, and for this reason the combined prediction model for LRVSO in this study was more effective than the CHA2DS2-VASc score.

A Study of Major and Minor Complications of 1500 Transvenous Lead Extraction Procedures Performed with Optimal Safety at Two High-Volume Referral Centers.

Background: Transvenous lead extraction (TLE) is the preferred management strategy for complications related to cardiac implantable electronic devices. TLE sometimes can cause serious complications. Methods: Outcomes of TLE procedures using non-powered mechanical sheaths were analyzed in 1500 patients (mean age 68.11 years; 39.86% females) admitted to two high-volume centers. Results: Complete procedural success was achieved in 96.13% of patients; clinical success in 98.93%, no periprocedural death occurred. Mean lead dwell time in the study population was 112.1 months. Minor complications developed in 115 (7.65%), major complications in 33 (2.20%) patients. The most frequent minor complications were tricuspid valve damage (TVD) (3.20%) and pericardial effusion that did not necessitate immediate intervention (1.33%). The most common major complication was cardiac laceration/vascular tear (1.40%) followed by an increase in TVD by two or three grades to grade 4 (0.80%). Conclusions: Despite the long implant duration (112.1 months) satisfying results without procedure-related death can be obtained using mechanical tools. Lead remnants or severe tricuspid regurgitation was the principal cause of lack of clinical and procedural success. Worsening TR(Tricuspid regurgitation) (due to its long-term consequences), but not cardiac/vascular wall damage; is still the biggest TLE-related problem; when non-powered mechanical sheaths are used as first-line tools.

The Influence of Lead-Related Venous Obstruction on the Complexity and Outcomes of Transvenous Lead Extraction.

BACKGROUND: Little is known about lead-related venous stenosis/occlusion (LRVSO), and the influence of LRVSO on the complexity and outcomes of transvenous lead extraction (TLE) is debated in the literature. METHODS: We performed a retrospective analysis of venograms from 2909 patients who underwent TLE between 2008 and 2021 at a high-volume center. RESULTS: Advanced LRVSO was more common in elderly men with a high Charlson comorbidity index. Procedure duration, extraction of superfluous leads, occurrence of any technical difficulty, lead-to-lead binding, fracture of the lead being extracted, need to use alternative approach and lasso catheters or metal sheaths were found to be associated with LRVSO. The presence of LRVSO had no impact on the number of major complications including TLE-related tricuspid valve damage. The achievement of complete procedural or clinical success did not depend on the presence of LRVSO. Long-term mortality, in contrast to periprocedural and short-term mortality, was significantly worse in the groups with LRSVO. CONCLUSIONS: LRVSO can be considered as an additional TLE-related risk factor. The effect of LRVSO on major complications including periprocedural mortality and on short-term mortality has not been established. However, LRVSO has been associated with poor long-term survival.

Analysis of Risk Factors for Major Complications of 1500 Transvenous Lead Extraction Procedures with Especial Attention to Tricuspid Valve Damage.

BACKGROUND: Transvenous lead extraction (TLE) is a relatively safe procedure, but it may cause severe complications such as cardiac/vascular wall tear (CVWT) and tricuspid valve damage (TVD). METHODS: The risk factors for CVWT and TVD were examined based on an analysis of data of 1500 extraction procedures performed in two high-volume centers. RESULTS: The total number of major complications was 33 (2.2%) and included 22 (1.5%) CVWT and 12 (0.8%) TVD (with one case of combined complication). Patients with hemorrhagic complications were younger, more often women, less often presenting low left ventricular ejection fraction (LVEF) and those who received their first cardiac implantable electronic device (CIED) earlier than the control group. A typical patient with CVWT was a pacemaker carrier, having more leads (including abandoned leads and excessive loops) with long implant duration and a history of multiple CIED-related procedures. The risk factors for TVD were similar to those for CVWT, but the patients were older and received their CIED about nine years earlier. Any form of tissue scar and technical problems were much more common in the two groups of patients with major complications. CONCLUSIONS: The risk factors for CVWT and TVD are similar, and the most important ones are related to long lead dwell time and its consequences for the heart (various forms of fibrotic scarring). The occurrence of procedural complications does not affect long-term survival in patients undergoing lead extraction.

Transvenous Lead Extraction without Procedure-Related Deaths in 1000 Consecutive Patients: A Single-Center Experience.

BACKGROUND: Transvenous lead extraction (TLE) is now a first-line technique for the treatment of complications related to cardiac implantable electronic devices. The aim of the study was to demonstrate that it is possible to safely perform difficult TLE procedures with a maximum reduction of peri-procedural major complications. METHODS: A total of 1000 consecutive patients undergoing TLE in a single high-volume center from 2016 to 2019 were studied. All procedures were performed in a hybrid room or operating room by a specialized TLE team. TLE was performed under general anesthesia and monitored by transesophageal echocardiography, and the operating room was suitably equipped for immediate surgical intervention. The effectiveness and safety of the procedures were assessed, with particular emphasis on major complications. RESULTS: In all, 1952 leads with the mean implant duration of 111.7 ± 77.6 months had been extracted. Complete procedural success of patients was achieved in 95.9% and clinical success in 99.1%. Major complications, predominantly cardiac tamponade (63.3%), occurred in 22 patients (2.2%). Rapid diagnosis and immediate intervention were the key to a 100% survival in patients with this complication. CONCLUSION: Performing procedures in a hybrid operating room under general anesthesia in the presence of a cardiac surgeon and with the use of transesophageal echocardiography significantly improves the safety of transvenous lead extraction.

Transesophageal Echocardiography As a Monitoring Tool During Transvenous Lead Extraction-Does It Improve Procedure Effectiveness?

BACKGROUND: Transesophageal echocardiography (TEE) is a valuable tool for monitoring the patient during transvenous lead extraction (TLE), but the direct impact of TEE on the effectiveness and safety of TLE has not yet been documented. METHODS: The effectiveness of TLE and short-term survival were compared between two groups of patients: 2106 patients in whom TEE was performed before and after TLE and 1079 individuals in whom continuous TEE monitoring was used. The procedure-related risk of major complications was assessed using a predictive SAFeTY TLE score. RESULTS: The patients monitored by TEE were characterized by older age, more comorbidities and higher SAFeTY TLE scores (6.143 ± 4.395 vs. 5.593 ± 4.127; p = 0.004). Complete procedural success was significantly higher in the TEE-guided group (97.683% vs. 95.442%, p < 0.01). The rate of serious complications in the TEE-guided group was lower than the predictive SAFeTY TLE score-a reduction of 28.75% (p < 0.05). Periprocedural mortality in the TEE-guided and non-TEE-guided groups was zero vs. six deaths (p = 0.186). Short-term survival was comparable between the groups. CONCLUSIONS: Transesophageal echocardiography as a monitoring tool during transvenous lead extraction provides valuable results-higher rates of complete procedural success and a reduced risk of the most severe complications, thus preventing periprocedural deaths.