Female sex as an independent predictor of major complications during transvenous lead extraction.

BACKGROUND: Transvenous lead extraction (TLE) is increasingly performed, and accurate procedural risk assessment is essential. Female sex has been reported as a possible risk factor for major complications, but previous analyses rarely balanced procedural and clinical characteristics between sexes, leaving unclear whether the association reflects sex itself or greater anatomical-procedural susceptibility. OBJECTIVE: To assess whether female sex remains independently associated with major complications during TLE after extensive propensity-score balancing of clinical and procedural confounders. METHODS: We retrospectively analyzed 4290 patients undergoing non-laser TLE at three high-volume centers by one primary operator (2006-2024). Women were matched 1:1 to men on ten clinical and procedural covariates. Major complications (HRS/EHRA criteria) were the prespecified primary endpoint. Multivariable logistic regression including female sex and all matching covariates was performed; Kaplan-Meier and Cox mortality analyses were secondary and exploratory. RESULTS: After matching, 1197 women and 1197 men were well balanced. Despite comparable procedural complexity, major complications were more frequent in women (3.76% vs 1.50%; p<0.001), including hemopericardium (2.54% vs 0.75%; p=0.001) and rescue cardiac surgery (2.17% vs 0.75%; p=0.006); procedural success was similar. Female sex remained independently associated with major complications (OR 2.72, 95% CI 1.52-4.85; p<0.001), as did longer lead dwell time (OR 1.12 per year; p<0.001); higher hemoglobin was protective (OR 0.86 per g/dl; p=0.026). CONCLUSION: After extensive balancing of confounders, female sex remained independently associated with major complications during TLE, supporting further investigation of sex-related procedural vulnerability and refinement of TLE risk models.