A Novel Clinical Perspective on New Masses after Lead Extraction (Ghosts) by Means of Intracardiac Echocardiography

Abstract

Background: A lead-reactive fibrous capsule (FC) identified by ultrasounds as an atrial or ventricular lead thickness of more than 1 mm above the vendor-declared lead diameter (TL) and its local fibrotic attachment to the cardiac wall (FAC) have never been investigated in vivo, so their relationship with post-extraction masses (ghost) is not known. Methods: Intracardiac echocardiography (ICE) was performed twice during the same extraction procedure in 40 consecutive patients: before and immediately after infected lead extraction Results: The ghost detection rate was high: 60% (24/40 patients); ICE could identify both TL and FAC, TL being noted in 25/40 (62%) patients and FAC in 12/40 patients (30%). Both TL and FAC were significantly associated with ghosts (p < 0.001 and p = 0.002, respectively), but TL had a higher prediction power. The specificity was similar: 94% (15/16) and 100% (16/16), respectively, but TL showed a much higher sensitivity: 100%, (24/24) vs 50% (12/24) (p = 0.016). The ghost group did not show a higher event rate in the follow-up (mean follow-up time = 20 ± 17 months). Conclusion: ICE is able to evaluate both TL and FAC in vivo; ghosts are mostly benign remnants of fibrotic lead capsule cut off during extraction and retained inside the heart by FAC.

Treatment and Prevention of Cardiovascular Implantable Electronic Device (CIED) Infections

“…Intracardiac echocardiography (ICE) has demonstrated high sensitivity for detection of vegetations on cardiac devices and has at times been utilized during lead extraction, but is not routinely performed. 36 TEE should be done to evaluate the left-sided heart valves, even if transthoracic views have demonstrated lead-adherent masses.…”

Novel way of patent foramen ovale detection and percutaneous closure by intracardiac echocardiography: A case report

“…ICE can be used to easily visualise the posterior and inferior rims of the interatrial septum. Additionally, ICE can help visualise clinical problems such as lead endocarditis masses and post-lead extraction floating masses inside the right atrial chamber[ 9 , 10 ]. Moreover, TEE reportedly misses the diagnosis in approximately 10% of patients[ 11 ].…”

Clinical utility of intracardiac echocardiography in transvenous lead extraction

“…The presence of ghosts was irst described by Rizzello, et al using ICE [22]. Caiati, et al studied a cohort of 40 patients using ICE before and after TLE to document the relationship between thrombotic or ibrotic reactions to the lead and with subsequent occurrence of ghosts [23]. ICE could identify thickened lead (thickness ≥ 1 mm than the vendor declared thickness in at least one lead) and ibrotic attachment to the cardiac wall in a substantial number of subjects.…”