The impact of defects of the atrial septum on procedural complexity, complications, and outcomes of transvenous lead extraction

BACKGROUND: Patients with defects of the atrial septum (DAS) undergoing transvenous lead extraction (TLE) may be at increased risk of systemic embolism due to transient right-to-left shunting. However, data on the prevalence and clinical relevance of DAS in patients undergoing TLE remain limited. METHODS: This retrospective study included 3637 patients undergoing TLE between 2006 and 2024 with complete preprocedural assessment of the atrial septum and at least 3 years of follow-up. We evaluated the prevalence of DAS and its association with procedural complexity, major complications, and survival. RESULTS: DAS was identified in 3.71% of patients. Patent foramen ovale was present in 2.45%, secundum atrial septal defect in 1.15%, and both defects in 0.08%. Most defects were small, with predominant left-to-right shunting. Patients with DAS more frequently had lead-related infective endocarditis and vegetations on transesophageal echocardiography (p < 0.001). TLE procedures in patients with DAS were more complex, with longer extraction times and more frequent use of advanced extraction tools. Despite higher predicted procedural risk, the incidence of major complications, including stroke, was low. DAS was not associated with increased in-hospital, 30-day, 1-year, or 3-year mortality. CONCLUSIONS: In this large TLE cohort, DAS was uncommon and associated with greater procedural complexity, but not with a higher incidence of major complications or worse long-term survival. Clinically apparent systemic embolic events were rare.