With the expanding use of cardiac implantable electronic device (CIEDs) in older populations with more complicated conditions have bring about higher rates of CIED infections. We report four cases of CIED infections from single-center, who were extracted endocardial leads with intra-op transesophageal echocardiography (TEE) monitoring and guidance. Three of them had fatal complications as pulmonary embolism, pericardial tamponade and tricuspid trauma. The other one was found a massive vegetation detected by TEE not by pre-op transthoracic echocardiogram (TTE), which could avoid intra-op embolism. Application of TEE helps improving efficacy and safety by capacitating the operators to perform the procedure, guiding them to better plans and to rapidly recognize and manage relative complications. Thus, continuously intra-op TEE should be one of the routine monitoring methods in this high-risk procedure.