A Ghost Left Behind After Transvenous Lead Extraction: A Finding to be Feared.

BACKGROUND Following transvenous lead extraction (TLE) for infective endocarditis, a fibrinous remnant, or "ghost", that previously encapsulated the lead may remain. The main aim of this case report was to highlight the importance of identification of ghosts, their negative implications, and the importance of close monitoring. CASE REPORT A 72-year-old male with a history of heart failure with non-ischemic cardiomyopathy and remote cardiac resynchronization therapy defibrillator (CRT-D) placement as well as atrioventricular node ablation for atrial fibrillation presented following a mechanical fall. An initial evaluation revealed methicillin-resistant Staphylococcus aureus bacteremia; the suspected nidus was an indwelling chemotherapy port for non-Hodgkin's lymphoma. Echocardiography demonstrated vegetations on the aortic and mitral valves, and the right atrial device lead concerning for infective endocarditis. After TLE, a temporary transvenous wire was placed. Definitive pacing was then achieved by a Micra leadless pacemaker (LP). We opted with LP technology via the Micra device with plan for subcutaneous implantable cardioverter defibrillator (SICD) implantation to mitigate the risk of infection recurrence. After completion of 6 weeks of antibiotics, a pre-SICD transesophageal echocardiogram identified a 1.3 cm mobile echo-dense "ghost" in the right atrium. SICD was implanted as planned. Following expert consensus, no specific therapy was implemented when the ghost was identified. At 3 months, echocardiography revealed the absence of the ghost. At 1-year follow-up, no infection recurrence was noted. CONCLUSIONS The presence of ghosts after transvenous lead extraction is associated with poor outcome and infection recurrence thus requiring diligent monitoring and serial echocardiography as optimal management is yet to be defined.

Cardiac resynchronization therapy and tools to identify responders.

Heart failure is a major epidemic. Many people with heart failure struggle with refractory symptoms despite optimal medical therapy. Those with severe left ventricular dysfunction and ventricular conduction delay are at significant risk from either dying suddenly or dying from progression of their heart failure. Cardiac resynchronization therapy (CRT) improves hemodynamics and symptoms of heart failure and has recently been shown to improve survival. One problem facing the use of CRT is that 30% of patients fail to respond. The dominant theory is that QRS duration (electrical dyssynchrony) does not accurately reflect mechanical dyssynchrony. Echocardiographic tools have recently been developed that enable clinicians to assess the degree of mechanical dyssynchrony in patients being considered for CRT. These tools are able to predict with a significant amount of accuracy whether a patient will respond to CRT. This allows for a more refined approach to evaluating patients for CRT and optimizing the treatment of congestive heart failure.