A new approach to the continuous monitoring of transvenous lead extraction using transesophageal echocardiography—Analysis of 936 procedures

Abstract

Aims: The usefulness of transesophageal echocardiographic (TEE) monitoring for transvenous lead extraction (TLE) procedures is still controversial. The purpose of the current study was to present new TEE values in detecting invisible events in fluoroscopy and preventing the development of dangerous complications. Methods: From 2015 to 2019, a total of 1026 procedures were performed in single TLE center. In total, 1108 leads had been extracted with a mean lead dwell time of 115.8 ± 77.6 months. Continuous TEE was used in 936 patients with a mean age of 67.1 ± 14.4 years. Results: Preprocedure examination revealed looped leads in 181 (19.3%) patients, dry cardiac perforation in 151 (16.1%), lead-to-lead adhesion in 172 (18.4%), lead adhesion to the myocardium in 317 (33.9%), and vegetations in 119 (12.7%) patients.Intra-procedural TEE demonstrated pulling on the atrial wall, ventricular wall, or tricuspid valve in 380 (40.5%), 235 (25.1%), and 78 (8.3%) patients, respectively. Acute tamponade requiring sternotomy occurred in 11 (1.1%) patients. Migration of vegetation or connective tissue fragments were seen in 69 (7.3%) and 111 (11.8%) patients, respectively. After procedure, TEE was helpful in navigating an implantation, a new lead in 97 (10.3%) patients, and removing the remnants of lead/silicone insulation in 50 (5.3%) patients. Conclusion:Real time transesophageal echocardiography for the guidance of transvenous lead extraction informs the operator about the danger of manipulations close to delicate cardiac structures and whether immediate modification to the plan of lead removal is necessary in order to prevent the occurrence of unwanted events. K E Y W O R D S continuous echocardiographic monitoring, transesophageal echocardiography, transvenous lead extraction

Transesophageal echocardiography for the monitoring of transvenous lead extraction

“…Assessment of the dynamics of bleeding helps the operator make an extremely important decision whether a chest drain is required, or whether it is enough to monitor the patient if the bleeding stops. In an emergency situation usually there is no time for inserting an esophageal probe and starting diagnostic imaging [12][13][14][15][16][17][18].…”

“…Severe structural damage to the tricuspid valve may cause acute right ventricular failure requiring urgent valve repair [22]. TEE monitoring during TLE offers a possibility of immediate detection, localization and evaluation of the complications and sequelae, especially: pericardial tamponade, damage to the tricuspid valve and migration of the embolic material, However, TEE is a valuable imaging tool not only because of the potential for early detection of difficulties, but also because intraoperative navigation helps extractors dissect the leads slowly and gradually and observe with close scrutiny the accompanying phenomena to prevent complications at all [17,18].…”

“…Removal of adherent leads requires strong pulling on the lead and cardiac structures to which it is attached. Informing the extractor about binding sites and monitoring during dissecting sheath (polipropulene, mechanical rotational) manipulation facilitates the timely modification of the extraction technique to maximize procedure efficacy and minimize potential complications [17,18] (Fig. 2).…”

“…Competent differentiation of structures remaining in cardiac cavities and vascular lumen after TLE is an important component of postprocedural assessment [1,2,18,25]. Connective tissue structures should be distinguished from remnants of vegetations, fragments of not extracted leads or insulation, as it is of vital importance for further treatment and clinical management.…”

“…Another important advantage of 2D and 3D TEE in patients undergoing TLE is a possibility of visualizing and monitoring percutaneous removal of silicone tube remnants left in cardiac cavities after TLE [16]. Insulation fragments remaining lodged in cardiac cavities are rarely described in the literature [18,27,31]. The silicone tube is invisible on fluoroscopy, that is why intraprocedural TEE is so important (Fig.…”