Two-Stage Transvenous Implantable Cardioverter-Defibrillator Lead Extraction Guided by 3D Transesophageal Echocardiography in Severe Cardiomyopathy: A Case Report.

Transvenous pacer and defibrillator lead extraction is the standard treatment for cardiac implantable electronic device (CIED) infection but carries significant procedural risk, particularly in patients with advanced cardiomyopathy, active infection, and long-standing lead dwell times. A 54-year-old male with nonischemic cardiomyopathy (ejection fraction <20%) and end-stage renal disease on hemodialysis presented with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia in the setting of a biventricular implantable cardioverter-defibrillator (ICD) placed 13 years earlier. Echocardiography demonstrated severe systolic dysfunction and a mobile echodensity consistent with vegetation on a pacemaker lead near the superior vena cava-right atrial junction, necessitating complete device extraction. Initial laser-assisted extraction in the operating room under general anesthesia with invasive monitoring and transesophageal echocardiography (TEE) guidance successfully removed one lead, but a second lead could not be fully extracted despite attempted removal. The patient was maintained on targeted intravenous antibiotics, and completion extraction was performed two weeks later; however, multiple conventional snaring attempts were unsuccessful due to lead orientation and adherence within the right atrium. Three-dimensional TEE (3D-TEE) was subsequently used to improve spatial visualization, enabling successful femoral snare capture and removal of the retained lead without complication. This case highlights the importance of procedural planning and advanced imaging in high-risk lead extraction, as a staged approach may mitigate risk while 3D-TEE provides critical real-time spatial guidance when conventional techniques fail.