A Ghost Left Behind After Transvenous Lead Extraction: A Finding to be Feared

Abstract

Patient: Male, 72-year-old Final Diagnosis: Infective endocarditis Symptoms: Falls • weakness Medication: — Clinical Procedure: Removal of pacemaker Specialty: Cardiology Objective: Rare disease Background: Following transvenous lead extraction (TLE) for infective endocarditis, a fibrinous remnant, or “ghost”, that previously encapsulated the lead may remain. The main aim of this case report was to highlight the importance of identification of ghosts, their negative implications, and the importance of close monitoring. Case Report: A 72-year-old male with a history of heart failure with non-ischemic cardiomyopathy and remote cardiac resynchronization therapy defibrillator (CRT-D) placement as well as atrioventricular node ablation for atrial fibrillation presented following a mechanical fall. An initial evaluation revealed methicillin-resistant Staphylococcus aureus bacteremia; the suspected nidus was an indwelling chemotherapy port for non-Hodgkin’s lymphoma. Echocardiography demonstrated vegetations on the aortic and mitral valves, and the right atrial device lead concerning for infective endocarditis. After TLE, a temporary transvenous wire was placed. Definitive pacing was then achieved by a Micra leadless pacemaker (LP). We opted with LP technology via the Micra device with plan for subcutaneous implantable cardioverter defibrillator (SICD) implantation to mitigate the risk of infection recurrence. After completion of 6 weeks of antibiotics, a pre-SICD transesophageal echocardiogram identified a 1.3 cm mobile echo-dense “ghost” in the right atrium. SICD was implanted as planned. Following expert consensus, no specific therapy was implemented when the ghost was identified. At 3 months, echocardiography revealed the absence of the ghost. At 1-year follow-up, no infection recurrence was noted. Conclusions: The presence of ghosts after transvenous lead extraction is associated with poor outcome and infection recurrence thus requiring diligent monitoring and serial echocardiography as optimal management is yet to be defined.

Discussing the Prognosis and Complications of Transvenous Lead Extraction in Patients With Cardiac Implantable Electronic Devices (CIED): A Systematic Review

“…The primary pathophysiology of ghost development is the invasion of lead capsules by fibrous tissue and blood vessel migration [ 31 ]. It is difficult for leads to move because of this interaction between heart tissues and leads, which also makes thrombus formation possible [ 31 , 35 , 36 ]. ​​The most reliable indicator of ghosts is how much the connective tissue surrounding the lead has grown and developed before TLE [ 27 ].…”

“…The primary pathophysiology of ghost development is the invasion of lead capsules by fibrous tissue and blood vessel migration [31]. It is difficult for leads to move because of this interaction between heart tissues and leads, which also makes thrombus formation possible [31,35,36].…”

Antibacterial Designs for Implantable Medical Devices: Evolutions and Challenges

“…Antibiotic resistance in bacteria even multidrug-resistant (MDR) bacteria is now a worldwide challenge [ 91 ]. Antibiotic-resistant infections were frequently reported all over the world, including in both developing and developed countries ( Table 4 ) [ 92 , 93 , 94 , 95 , 96 , 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 ]. During an infection, Staphylococcus aureus ( S. aureus ) often forms biofilms on implantable devices, which dramatically increases the ability of the species to acquire resistance via horizontal plasmid transfer [ 111 ].…”

“…This is why S. aureus has high rates of resistance. As shown by the typical cases reported in recent years ( Table 4 ), MRSA has become the most common strain causing infections of various implantable medical devices, including cardiac devices [ 93 , 95 , 99 , 103 , 106 ], orthopedic prosthetics [ 96 , 97 ], cochlear implants [ 98 ], breast implants [ 100 ], laryngeal implants [ 101 ], and stent grafts [ 109 ]. In addition, there is an alarming increase in antibiotic resistance in other strains, such as Acinetobacter baumannii [ 92 ], Mycobacterium chelonae [ 94 ], Enterobacter cloacae complex [ 102 ], S. epidermidis [ 104 , 110 ], Klebsiella pneumoniae [ 105 ], Staphylococcus haemolyticus [ 107 ], and Staphylococcal endophthalmitis [ 108 ], are also involved in various resistant DAIs.…”

“…As shown by Table 3 and Table 4 , the latent period of a DAI can be days after implant placement [ 92 , 94 , 105 , 108 , 109 , 110 ], years after the surgery [ 78 , 79 , 93 , 95 ], or even decades later [ 67 , 68 ]. This feature of DAIs lays the basis for the development of antibacterial surfaces with long active durations.…”