Intracardiac "Ghost" Following Implantable Cardioverter-Defibrillator (ICD) Explantation: The Role of Multimodality Imaging in Diagnosis and Management

Figures

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  Figure 1. Mid-esophageal bicaval TEE image at 0° demonstrating a large, elongated, highly mobile echodense structure attached near the tricuspid annulus and extending into the right atrium TEE, transesophageal echocardiography

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  Figure 2. Mid-esophageal bicaval TEE image at 50° showing a tubular intracardiac structure within the right atrium TEE, transesophageal echocardiography

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  Figure 3. Transgastric right ventricular inflow TEE image at 66° confirming the filamentous, mobile configuration of the structure TEE, transesophageal echocardiography

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  Figure 4. CMR images showing highly mobile formations within the right atrium, pedunculated and arising from the tricuspid valve, the right atrial appendage, and the superior vena cava. The structures demonstrate signal intensity similar to myocardium on T1-weighted sequences, without evidence of perfusion, and with heterogeneous contrast enhancement predominantly at their periphery CMR, cardiac magnetic resonance

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  Figure 5. Mid-esophageal bicaval TEE image at 0° demonstrating a reduction in the size of the mobile echodense structure attached near the tricuspid annulus and extending into the right atrium TEE, transesophageal echocardiography

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  Figure 6. CTPA axial contrast-enhanced image demonstrating an intraluminal filling defect within a segmental branch of the right lower lobe pulmonary artery (arrow), suggestive of pulmonary embolism CTPA, computed tomography pulmonary angiography

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  Figure 7. Mid-esophageal bicaval TEE image at 0° demonstrating the absence of the structure TEE, transesophageal echocardiography

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  Figure 8. Schematic illustration of the pathophysiologic mechanism underlying “ghost” formation following transvenous lead explantation Chronic mechanical interaction between the intracardiac lead and endocardium promotes fibrin deposition and progressive fibrotic encapsulation. Following lead removal, a residual fibrotic sheath may persist, appearing as a mobile intracardiac structure (“ghost”), with the potential for embolization or spontaneous resolution. Image credit: Created by the authors using Microsoft PowerPoint (Microsoft, Redmond, WA).

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  Figure 9. Patient’s journey/clinical timeline TEE, transesophageal echocardiography; MRSA, methicillin-resistant Staphylococcus aureus; CIED, cardiac implantable electronic device; ICD, implantable cardioverter-defibrillator; CMR, cardiac magnetic resonance; CTPA, computed tomography pulmonary angiography Image credit: Created by the authors using Microsoft PowerPoint (Microsoft, Redmond, WA).