Chronic fibrous sheath mistaken for retained pacemaker product

A 71-year-old man underwent implantation of a single-chamber system in 1988 for sinoatrial disease, which was then upgraded to dual-chamber 7 years later following recurrent syncope. He presented with pacemaker erosion but without clinical or laboratory evidence of infective endocarditis. The pacemaker system was uneventfully extracted 5 days later via a transfemoral approach using a needle-eye snare. A post-procedure trans-thoracic echocardiogram was performed, which demonstrated an echogenic structure in the right atrium-this was initially felt to be a retained fragment of pacing lead. A short-axis view of the tricuspid valve with a bright linear echo crossing is shown in Figure 1. However, a post-procedural chest X-ray confirmed the absence of any retained intra-cardiac lead. The reverberant cast-like structure noted is a heavily calcified fibrous sheath as the pacing leads were confirmed to be intact at the time of removal.