Maria Lucia Narducci (Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Rome, Italy) and others report in Europace that the presence of residual fibrous tissue—or “ghosts”—after transvenous lead extraction is associated with a significantly increased risk of death. The authors add that “ghosts” probably represent a “constellation of features” that affect clinical outcome.
Narducci et al write that a “ghost” after transvenous lead extraction is defined as “a post-removal tubular mass detected by echocardiography” and that “this ghost might be associated with persistent cardiac device-related infective endocarditis and consequently with a worse long-term outcome.” They add that the long-term outcomes of patients—including those with ghosts—who have undergone transvenous lead extraction is not known. Therefore, in this prospective study, the authors aimed to “identify the clinical predictors of ghosts detected by intracardiac echocardiography and transoesophageal echocardiography after transvenous lead extraction and their possible correlation to patients’ outcome.”
All of the 217 patients enrolled in the study underwent lead extraction, with 95% of them undergoing the procedure for systemic or local infection (64% with systemic device infection) and 5% undergoing the procedure for lead malfunction. Overall, 14% of patients had ghosts—as identified by intracardiac echocardiography (confirmed with transoesophageal echocardiography)—but all of these patients were those who had undergone lead extraction for local or systemic infection. Narducci et al found, after performing a multiple logical regression analysis, that “the only independent predictors of ghosts were Charlson comorbidity index and intracardiac echocardiography-guided diagnosis of endocarditis (p=0.03 and p=0.04, respectively).”
At both three and 12 months of follow-up, patients with ghosts had a significantly lower survival rate compared with those without ghosts: 71% vs. 93%, respectively (p=0.002). Furthermore, after adjusting for systemic infection and preoperative endocarditis, the authors found that the presence of a ghost was an independent predictor of mortality (p=0.002). They comment that the finding that ghosts were associated with an independent risk of death “probably reflects the fact that they represent a marker of a constellation of features with a clinical impact on outcome”, explaining these features include older age, endocarditis, and comorbidities (Charlson comorbidity index >1)—“all variables recognised to be associated with higher mortality on follow-up after transvenous lead extraction.”
According to Narducci et al, the presence of ghosts “appears to identify a sicker population which is at higher risk of death” and they comment: “For such patients, as well as patients with systemic infection (also associated with an independent risk of death in the study), careful monitoring, closure follow-up, and prompt tailored therapies are warranted to prevent worsening or complications.” “Large prospective multicentre studies are warranted to establish prognosis and the best management options in this high-risk population,” the authors conclude.
