The prognostic value of transesophageal echocardiography after transvenous lead extraction: landscape after battle

Abstract

Background: In patients undergoing transvenous lead extraction (TLE) transesophageal echocardiography (TEE) provide valuable information after procedure.

Methods: We analyzed data from 936 TEE performed in patients undergoing TLE between 2015 and 2019 (mean follow-up 566.23±224.47 days) and assessed the role of echocardiographic phenomena after procedure.

Results: Increment in tricuspid regurgitation (TR) was observed in 9% of patients after TLE. Factors increasing the risk of TR were: binding sites between lead and right ventricle (RV) (OR: 5.429), tricuspid valve (TV) (OR: 3.42), superior vena cava (SVC) (OR: 3.30) and lead-to-lead adhesions (OR: 2.88). Predisposing factors of residual structures after TLE were: asymptomatic masses on the leads (AMEL) (OR: 1.68), binding sites between SVC and cardiac structures (OR: 1.72), and multiple leads (OR: 1.30). Probability of vegetation remnants increased in the presence of abandoned leads (OR: 7.91). The risk factors of tamponade were: dwell time of the oldest lead (OR: 1.17), lead-to-lead adhesion (OR: 22.47), binding sites between lead and TV (OR: 6.08), RA (OR: 11.50), SVC (OR: 4.47), higher LVEF (OR: 2.35; P=0.006), female gender (OR: 5.43), multiple leads (OR: 2.11), looped leads (OR: 4.90) and AMEL (OR: 6.42). The risk of lead fracture was increased by: lead-to-lead adhesion (OR: 5.69), fibrosis binding the lead to RV (OR: 5.16), RA (OR: 2.39) and dwell time of the oldest lead (OR: 1.068). The mortality rate was 11.97% during follow-up. The risk of death was increased by: severe TR and vegetation remnants.

Conclusions: The most important phenomena evaluated after TLE are: tricuspid valve function, residual fibrosis and vegetation remnants, progression of pericardial effusion and retained lead fragments. Postoperative TEE provides information about the results of TLE and helps establish further management.

Keywords: Transvenous lead extraction (TLE); connective tissue scar; lead extraction-related tricuspid valve damage; retained lead fragments; transesophageal echocardiography (TEE); vegetation remnants.

Figure 1

Damage to the tricuspid valve during TLE demonstrable by TEE. Red arrow: adhesion of the lead to the posterior leaflet (yellow arrow); green arrow: anterior leaflet; blue arrow: lead in the right atrium.

Figure 2

Kaplan-Meier estimates of the probability of free of death survival depending on the grade of tricuspid valve regurgitation after TLE. P<0.001.

Figure 3

Improvement in TR after removal of the lead impinging on the leaflet. The arrows show the course of the lead colliding with the tricuspid valve leaflet.

Figure 4

Residual fibrosis demonstrated in postoperative TEE (blue arrows). Red arrow: lead during extraction.

Figure 5

Kaplan-Meier estimates of the probability of free of death survival depending on the presence or absence of vegetation remnants after TLE. P<0.001.

Figure 6

Embolic protection during TLE in patients at high risk of large vegetation dislodgement. Green arrows: large vegetation; red arrow: lead; blue arrows: basket in pulmonary trunk. TLE, transvenous lead extraction.

Figure 7

Vegetation remnants in postoperative TEE. Red arrows show lead before extraction. TEE, transesophageal echocardiography.

Figure 8

Extraction of 26-year-old DDD leads in a 58-year-old woman complicated with pericardial tamponade as a result of RAA perforation. Red arrows: leads; blue arrow: lead-to-lead adhesion; yellow arrow: fluid (blood) in pericardium.

Figure 9

Fragments of leads broken during TLE and demonstrated in TEE (arrows and circles). TLE, transvenous lead extraction; TEE, transesophageal echocardiography.