IMAGE Materialization of ghosts: Severe intracardiac masses after pacemaker lead extraction requiring immediate surgical intervention Martin Andreas, MD, MBA, Dominik Wiedemann, MD, Alfred Kocher, MD, Cesar Khazen, MD From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria. Thirteen years after 2-chamber pacemaker implantation, a 50-year-old patient was referred for pacemaker lead ex- traction because of pocket infection. Lead extraction was performed with an 11-F Evolution Mechanical Dilator Sheath Set (Cook Medical, Inc, Bloomington, IN) in the operating theatre with cardio- pulmonary bypass standby. The intraoperative preinter- ventional transesophageal echocardiography revealed no vegetations on the pacemaker leads. However, after com- plete extraction, an inhomogeneous highly mobile struc- ture of 3.7 cm was seen in the right atrium, also referred to as “ghost” (Figure 1). Sudden cardiac death and symp- tomatic pulmonary embolism were reported as potential sequels. 1,2 Because of the high mobility of this big struc- ture, the decision for acute surgical intervention on car- diopulmonary bypass was made. The structure was fragmented during extraction. Some frag- ments could be retrieved via an incision of the pulmonary artery; the majority were removed through a right atrial access and the tricuspid valve ( Figure 2). The histological analyses described the ghost as organized thrombus without signs of infection. Lead vegetations with infected thrombotic material are possi- ble causes for pulmonary embolism but can be degraded because of the high thrombolytic capacity of the pulmonary vascular bed. On the contrary, transvenous leads are known to cause chronic thrombotic processes leading to a fibrous or even calcified cover of the leads. 3 In this image, the ghost represents chronic throm- botic material with a high grade of fibrous tissue. The channel of one lead could be identified on the biggest fragment. Therefore, any degradation of this material is unlikely. The postoperative course was uneventful, and the patient fully recovered. Echo guidance during the primary proce- dure and a rapid surgical intervention are reasonable to extract mobile masses of significant size. References 1. Le Dolley Y, Thuny F, Mancini J, et al. Diagnosis of cardiac device-related infective endocarditis after device removal. JACC Cardiovasc Imaging 2010;3:673– 681. 2. Novaro GM, Saliba W, Jaber WA. Images in cardiovascular medicine: fate of intracardiac lead vegetations after percutaneous lead extraction. Circulation 2002;106:e46. 3. Candinas R, Duru F, Schneider J, Luscher TF, Stokes K. Postmortem analysis of encapsulation around long-term ventricular endocardial pacing leads. Mayo Clin Proc 1999;74:120 –125. KEYWORDS Lead extraction; Ghost; Lead vegetation; Pocket infection; Pacemaker lead (Heart Rhythm 2013;10:1826) Address for reprint requests and correspondence: Dr Martin Andreas, MD, MBA, Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, Level 20A, 1090 Vienna, Austria. E-mail address: martin.andreas@meduniwien.ac.at. Figure 2 Figure 1 1547-5271/$ -see front matter © 2013 Heart Rhythm Society. All rights reserved. http://dx.doi.org/10.1016/j.hrthm.2012.05.026