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

Carlo Caiati,Paolo Pollice,Giovanni Luzzi,Mario Erminio Lepera,Stefano Favale

doi:10.3390/jcm9082571

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.

Highlights

Infection of cardiac implantable electronic devices (CIEDs)—such as permanent pacemakers and implantable cardioverter defibrillators—is a severe occurrence associated with high mortality [1]
In our preliminary experience, we found that the thickness of the newly implanted lead can be correctly assessed by transthoracic echocardiography (TTE), so we hypothesized first, that a highly sensitive imaging technique like intracardiac echocardiography (ICE) [13] has the potential to investigate thrombotic/fibrotic reactions involving the leads, in particular assessing lead thickness
Ghosts were defined as new, post-removal, mobile masses visualized by ultrasound (ICE and/or transesophageal echocardiography (TEE) postprocedural) [3]; we collected information about the localization, shape and sizes of ghosts and we investigated the association with cardiac device-related infective endocarditis (CDRIE), positive blood and lead culture after extraction, number of leads removed and age of the leads

Summary

Introduction

Infection of cardiac implantable electronic devices (CIEDs)—such as permanent pacemakers and implantable cardioverter defibrillators—is a severe occurrence associated with high mortality [1]. In our preliminary experience (unpublished), we found that the thickness of the newly implanted lead can be correctly assessed by transthoracic echocardiography (TTE), so we hypothesized first, that a highly sensitive imaging technique like intracardiac echocardiography (ICE) [13] has the potential to investigate thrombotic/fibrotic reactions involving the leads, in particular assessing lead thickness. That this ICE-detected fibrotic reaction could be a strong predictor of “ghost” masses. 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

Methods

Results

Conclusion