Free
Education  |   July 2019
A Ghost in the Heart
Author Notes
  • From the Department of Anesthesiology and Perioperative Medicine, Augusta University, Augusta, Georgia.
  • Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
    Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).×
  • Address correspondence to Dr. Agarwal: Sagarwal@augusta.edu
Article Information
Education / Images in Anesthesiology / Cardiovascular Anesthesia
Education   |   July 2019
A Ghost in the Heart
Anesthesiology 7 2019, Vol.131, 150. doi:https://doi.org/10.1097/ALN.0000000000002665
Anesthesiology 7 2019, Vol.131, 150. doi:https://doi.org/10.1097/ALN.0000000000002665
This midesophageal bicaval view on transesophageal echocardiography shows a tubular residual floating mass often referred to as a “ghost” emerging from the superior vena cava (SVC) and floating freely in the right atrial (RA) cavity immediately after a transvenous lead extraction (see Supplemental Digital Content, http://links.lww.com/ALN/B900; LA in the image indicates left atrium and IVC indicates inferior vena cava). The increasing number of patients with cardiovascular implantable electronic devices in recent years has led to a growing need for transvenous lead extractions, the main indications for which are cardiac device–related infective endocarditis, local device infection, lead dysfunction, and device upgrading. In about 8 to 14% of transvenous lead extractions, such ghosts have been detected on imaging studies, the pathophysiology of which can be explained by the growth of a fibrous sleeve around the lead.1  These structures may persist indefinitely after laser lead extraction, can often be confused as thrombi or vegetations during echocardiography, and are a potential source of pulmonary embolism.2 
Although occasionally seen after transvenous lead extraction in the context of reactive pericarditis without any known infectious causes,3  the presence of ghosts after transvenous lead extraction has almost exclusively been associated with a preoperative diagnosis of either cardiac device–related infective endocarditis and local device infection in both retrospective and prospective studies, suggesting that infection may be the driver for ghost development.1  Such ghosts have been found to be independent predictors of mortality, increasing mortality by more than three times at midterm follow-up. This information, when communicated to the cardiologists, can help them identify this subgroup of patients who need closer clinical surveillance postoperatively.1 
Competing Interests
The authors declare no competing interests.
References
Narducci, ML, Di Monaco, A, Pelargonio, G, Leoncini, E, Boccia, S, Mollo, R, Perna, F, Bencardino, G, Pennestrì, F, Scoppettuolo, G, Rebuzzi, AG, Santangeli, P, Di Biase, L, Natale, A, Crea, F . Presence of “ghosts” and mortality after transvenous lead extraction. Europace. 2017; 19:432–40. [PubMed]
Maddali, MM, Panduranga, P, Kaza, SR, Al-Lawati, AA, Mukhaini, MK, Khamis, FA . Transvenous pacemaker lead vegetation. J Cardiothorac Vasc Anesth. 2011; 25:600–2. [Article] [PubMed]
Bentivegna, R, Cattafi, G, Giannattasio, C, Moreo, A . Unusual presence of “ghosts” following lead extraction for recurrent reactive pericarditis: A case report. Eur Heart J Case Rep. 2018; 2:1–5.