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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