title: Presence of 'ghosts' and mortality after transvenous lead extraction.
abstract: OBJECTIVE
  The number of cardiovascular implantable electronic devices has increased progressively, leading to an increased need for transvenous lead extraction (TLE) due to device infections. Previous studies described 'ghost' as a post-removal, new, tubular, mobile mass detected by echocardiography following the lead's intracardiac route in the right-sided heart chambers, associated with diagnosis of cardiac device-related infective endocarditis. We aimed to analyse the association between 'ghosts' assessed by transesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) and mortality in patients undergoing TLE.
  
  
  RESULTS
  We prospectively enrolled 217 patients (70 ± 13 years; 164 males) undergoing TLE for systemic infection (139), local device infection (67), and lead malfunction (11). All patients underwent TEE before and 48 h after TLE and ICE during TLE. Patients were allocated to two groups: either with (Group 1) or without (Group 2) post-procedural 'ghost'. Mid-term clinical follow-up was obtained in all patients (11 months, IQR 1-34 months). We identified 30 (14%) patients with 'ghost', after TLE. The significant predictors of 'ghost' were Charlson co-morbidity index (HR = 1.24, 95% CI 1.04-1.48, P = 0.03) and diagnosis of endocarditis assessed by ICE (HR = 1.82, 95% CI 1.01-3.29, P = 0.04). Mortality was higher in Group 1 than in Group 2 (28 vs. 5%; log-rank P < 0.001). Independent predictors of mid-term mortality were the presence of 'ghost' and systemic infection as the clinical presentation of device infection (HR = 3.47, 95% CI 1.18-10.18, P = 0.002; HR = 3.39, 95% CI 1.15-9.95, P = 0.001, respectively).
  
  
  CONCLUSIONS
  The presence of 'ghost' could be an independent predictor of mortality after TLE, thus identifying a subgroup of patients who need closer clinical surveillance to promptly detect any complications.
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Maria Lucia
authors.initials: ML
authors.lastname: Narducci
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Di Monaco
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Gemma
authors.initials: G
authors.lastname: Pelargonio
authors.affiliation: Section of Hygiene, Institute of Public Health, Catholic University of Sacred Heart, Rome, Italy.
authors.forename: Emanuele
authors.initials: E
authors.lastname: Leoncini
authors.affiliation: Section of Hygiene, Institute of Public Health, Catholic University of Sacred Heart, Rome, Italy.
authors.forename: Stefania
authors.initials: S
authors.lastname: Boccia
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Mollo
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Perna
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Bencardino
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Faustino
authors.initials: F
authors.lastname: Pennestrì
authors.affiliation: Department of Infectious Disease, Catholic University of Sacred Heart, Rome, Italy.
authors.forename: Giancarlo
authors.initials: G
authors.lastname: Scoppettuolo
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Antonio Giuseppe
authors.initials: AG
authors.lastname: Rebuzzi
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santangeli
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
authors.forename: Luigi
authors.initials: L
authors.lastname: Di Biase
authors.affiliation: Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Natale
authors.affiliation: Department of Cardiovascular Sciences, Catholic University of Sacred Heart, Largo A. Gemelli 8, 00168 Rome, Italy.
authors.forename: Filippo
authors.initials: F
authors.lastname: Crea
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017147:Defibrillators, Implantable / Q000009:adverse effects*; D020878:Device Removal / Q000009:adverse effects / Q000401:mortality*; D015150:Echocardiography, Doppler; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D010138:Pacemaker, Artificial / Q000009:adverse effects*; D011183:Postoperative Complications / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality*; D011446:Prospective Studies; D011475:Prosthesis Failure; D016459:Prosthesis-Related Infections / Q000175:diagnosis / Q000401:mortality* / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Cardiac rhythm device; Infective endocarditis; Intracardiac echocardiography; Transvenous lead extraction