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Mobile Thrombi Detected on Transvenous Leads in Lead Extraction
Study Questions:
What is the prevalence and clinical significance of thrombus on transvenous leads in patients undergoing lead extraction for noninfectious indications?
Methods:
Consecutive patients undergoing transvenous lead extraction for noninfectious indications were enrolled. A routine preoperative transesophageal echocardiography was performed prospectively for all patients on the day of the lead extraction procedure, focusing on all transvenous leads from the superior vena cava to endocardial insertion points to examine for mobile thrombus located in the intracardiac portion of the leads. Anticoagulation was not started for thrombus unless other indications were present. Clinical endpoints of mortality and cardiovascular morbidity (symptomatic pulmonary embolism, myocardial infarction, or cerebrovascular accident) were assessed at a minimum of 2-month follow-up.
Results:
A total of 108 patients underwent lead extraction for noninfectious indications. Lead thrombi were detected in 20 (18.5%) patients and all were <2 cm. Clinical and lead characteristics were not associated with formation of lead thrombi, except for younger patient age. In patients with detected thrombi, there were no short-term deaths, symptomatic pulmonary embolisms, or myocardial infarctions, except one patient with a stroke 3 months after lead extraction (7% vs. 5%; p = 1.00). Median follow-up was 9 months.
Conclusions:
Mobile thrombi on transvenous leads are commonly found in patients referred for transvenous lead extraction and are rarely associated with acute major adverse outcomes. Careful extraction of leads with small incidentally detected thrombi can likely be performed without major acute clinical sequelae. Larger studies with longer follow-up are needed to further assess the long-term clinical significance of lead thrombi.
Perspective:
This study showed that thrombi may be present in almost 20% of leads in patients undergoing lead extraction for noninfectious indications. Two prior prospective studies showed incidence of thrombi of 20% and 30%. Lead characteristics such as the number of leads, lead insulation material, cardiac chamber of lead fixation, abandoned lead status, and lead age did not predict thrombus formation. Given the very low number of events, the study was underpowered to detect acute adverse clinical events. Importantly, there were no acute complications, although the patients were not specifically assessed for subclinical chronic thromboembolic disease. It remains unknown whether anticoagulation in patients with incidentally discovered lead thrombus is of any clinical value.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Echocardiography/Ultrasound
Keywords: Anticoagulants, Arrhythmias, Cardiac, Echocardiography, Transesophageal, Heart Failure, Myocardial Infarction, Myocardium, Pulmonary Embolism, Stroke, Thromboembolism, Thrombosis, Vascular Diseases, Vena Cava, Superior
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