Conclusion
As with any procedure, the preparatory phase of TLE is critical, allowing the physician to anticipate challenges, ensure the availability of necessary tools and personnel, and ultimately, to counsel the patient on the safety and likely outcomes. The study by Aboelhassan et al in this issue of JCE supports the value of a simple venogram in planning for TLE. Ultimately, though, more work must be done to fully define the role of venography in this regard. A venogram cannot supplant CT, TEE, IVUS or ICE and in some cases, the added value may be minimal. Those other imaging modalities provide a depth of information that venography does not. CT, for instance, should be able to detect some adherence which might be missed by venography in a single projection. Additionally, CT provides a better assessment of lead adherence to cardiac structures. TEE, ICE and IVUS can all detect adherence of the leads to the veins as well as other structures and provide feedback in real time. In fact, TEE been shown to help rapidly detect major complications and provide reassurance during periods of transient hypotension.9
Aboelhassan et al should be commended for their excellent work demonstrating the ability of a simple venogram to predict complexity of TLE. Ipsilateral venography may deserve greater consideration as part of the planning for lead extraction. Still much remains to be done to improve our planning and thereby improve both safety and outcomes of TLE.
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