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

Figures

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  Figure 1. Example of a partially thickened lead at intracardiac echocardiography (ICE). Home view showing normal thickness of the proximal part of the lead in the right atrium (white arrow head), but evident thickening in the distal atrial part and in its ventricular course (≥4 mm, blue arrows); AO—aorta; RA—right atrium; RV—right ventricle; TV—tricuspid valve.

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  Figure 2. Side-by-side, a thickened lead at ICE and the same lead at visual inspection immediately after extraction. The ventricular lead (right side) is uniformly thickened at ICE. After extraction, the lead (left side) shows remnants of sheathing fibrosis in both the ventricular and atrial parts of the lead (arrows). Abbreviations as in Figure 1.

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  Figure 3. Fibrotic attachment to the cardiac wall (FAC) involving the atrial portion of a ventricular lead. Home view: FAC is visible as dense echoes encasing the atrial portion of a ventricular lead (arrow-heads), fixed to the atrial endocardium with loss of independent lead motion (such findings are better seen in the movie). FAC = lead fibrotic attachment to the cardiac wall; RA—right atrium; RV—right ventricle; TV—tricuspid valve.

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  Figure 4. Individual value bar graph of WBC count versus lead fibrosis. There is a significant, progressive mean increase in WBC, with a large effect size all the way up to the major classes of lead fibrosis, as assessed by ultrasound. (F = 9.007, p < 0.005 for trend, partial eta squared = 0.196); TL—thickened lead; FAC—fibrosis fixing the lead to the cardiac wall; WBC—white blood cell count.

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  Figure 5. Ghost after lead extraction by ICE. Modified home view by ante-flexion, to gain a close-up of the right ventricle. Mobile hypo-echogenic mass (arrows) in the right atrium attached at the origin of right atrial appendage. In the movie, other smaller floating masses are also seen, attached to the superior vena cava. RAA—right atrial appendage; other abbreviations as in Figure 3.

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  Figure 6. Ghost follow-up at 1 month. Individual value bar graph shows the destiny of the ghost as assessed by ICE (first column) and at 1 month follow-up by TEE (second column). Most of the ghost masses were still there (pink dots connected with solid line), while 7 had disappeared (triangles connected with dashed line). (2 masses, green triangles, were not assessed at follow-up because they were in an inaccessible part of the superior vena cava).

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  Figure 7. ROC curves. Left: bar graph showing the maximum individual measured lead thickness in patients with and without ghosts and the cutoff value (solid horizontal line). Right: plot of sensitivity against 1-specificity of the measured lead thickness (ROC curves) in predicting a ghost. A—area under the curve.