“Ghost”, a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance
Abstract
:1. Introduction
2. Materials and Methods
2.1. Study Population
2.2. TLE Indications
2.3. TEE Monitoring of the Lead Extraction Procedure
2.4. Definitions of Echocardiographic Phenomena
2.5. Lead Extraction Procedure
2.6. Approval of the Bioethics Committee
2.7. Statistical Analysis
3. Results
3.1. Uni- and Multivariable Linear Regression Analysis
3.2. Survival Analysis
4. Discussion
5. Conclusions
- In approximately 30% of TLE procedures ghosts remain attached to the CVS wall (SG) but in around 15% of the extraction procedures freed ghosts (FG) travel spontaneously to the pulmonary vascular bed and disappear.
- Younger patient age and the number of leads but not infectious indications are the factors predisposing to ghost formation during and after TLE.
- The degree of growth and maturation of the connective tissue surrounding the lead before TLE is the strongest predictor of both types of ghosts.
- The occurrence of ghosts is associated with complicated procedures, but it seems to be related to implant duration and scar growth.
- The presence of both types of ghosts does not reduce survival after TLE.
Study Limitations
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Patient Characteristics | Flying Ghosts (Ghosts Shifting Spontaneously to Pulmonary Vascular Bed) | Stable Ghosts (Ghosts Remaining Attached to Cardiovascular Wall) | Ghosts Absent during and after TLE |
---|---|---|---|
Group/number of patients | 1: N = 171 (15.50%) | 2: N = 322 (29.19%) | 3: N = 610 (55.31%) |
Form of result presentation | mean ± SD/n (%) p (1 vs. 2) | mean ± SD/n (%) p (2 vs. 3) | mean ± SD/n (%) p (1 vs. 3) |
Patient age during TLE [years] | 66.06 ± 16.20 p = 0.912 | 65.73 ± 15.29 p < 0.006 | 68.87 ± 13.38 p < 0.047 |
Patient age at first system implantation [years] | 53.53 ± 18.63 p = 0.044 | 56.21 ± 17.39 p = 0.028 | 59.37 ± 14.81 p < 0.001 |
Female | 70 (40.94) p = 0.654 | 140 (43.48) p = 0.260 | 232 (38.03) p = 0.267 |
Etiology: ischemic heart disease | 109 (63.72) p = 0.990 | 204 (63.35) p = 0.421 | 404 (66.23) p = 0.545 |
NYHA III & IV | 31 (18.13) p = 0.799 | 54 (16.77) p = 0.854 | 98 (16.07) p = 0.592 |
LVEF average [%] | 48.43 ± 15.07 p = 0.610 | 49.04 ± 14.86 p = 0.335 | 47.93 ± 15.82 p = 0.819 |
LVEF category: significantly decreased (<30%) | 24 (14.04) p = 0.714 | 40 (12.42) p = 0.101 | 102 (16.72) p = 0.468 |
Permanent atrial fibrillation | 39 (22.81) p = 0.937 | 71 (22.05) p = 0.499 | 148 (24.26) p = 0.770 |
Congestive heart failure | 58 (33.92) p = 0.085 | 84 (26.09) p = 0.652 | 169 (27.71) p = 0.137 |
Renal failure (any) | 34 (19.88) p = 0.451 | 75 (23.19) p = 0.313 | 162 (26.56) p = 0.377 |
Charlson comorbidity index | 5.175 ±4.185 p = 0.710 | 4.708 ± 3.746 p = 0.099 | 5.090 ± 3.671 p = 0.434 |
Univariable Regression | Multivariable Regression | |||||
---|---|---|---|---|---|---|
OR | 95% CI | p | OR | 95% CI | p | |
Flying ghosts | ||||||
Patient age at first system implantation [by year] | 0.977 | 0.967–0.987 | <0.001 | 0.984 | 0.970–0.997 | 0.019 |
Systemic infection | 0.526 | 0.301–0.920 | 0.024 | 0.539 | 0.289–1.006 | 0.052 |
Number of CIED-related procedures before TLE | 1.227 | 1.046–1.439 | 0.012 | 1.081 | 0.832–1.403 | 0.560 |
Dwell time of the oldest target lead in the patient before TLE [by year] | 1.060 | 1.035–1.085 | <0.001 | 0.988 | 0.946–1.033 | 0.607 |
Any form of scar tissue on the lead(s) | 10.34 | 5.625–19.02 | <0.001 | 7.106 | 3.424–14.75 | <0.001 |
Number of separate scars | 1.685 | 1.457–1.949 | <0.001 | 1.372 | 1.076–1.749 | 0.011 |
Lead adhesion to heart structures (any) | 2.811 | 1.961–4.028 | <0.001 | 0.517 | 0.281–0.953 | 0.034 |
Stable ghosts | ||||||
Patient age at first system implantation [by year] | 0.989 | 0.985–0.993 | <0.001 | 0.989 | 0.980–0.999 | 0.030 |
Charlson comorbidity index | 0.976 | 0.940–1.013 | 0.197 | |||
Abandoned lead before TLE | 1.883 | 1.207–2.938 | 0.005 | 1.152 | 0.653–2.032 | 0.623 |
Number of leads in the heart before TLE | 1.554 | 1.280–1.887 | <0.001 | 1.450 | 1.141–1.842 | 0.002 |
Number of CIED-related procedures before lead extraction | 1.127 | 0.981–1.296 | 0.092 | 0.940 | 0.786–1.124 | 0.499 |
All forms of scar tissue on the lead(s) | 2.304 | 1.708–3.106 | <0.001 | 1.940 | 1.293–2.909 | <0.001 |
Number of separate scars | 1.424 | 1.260–1.609 | <0.001 | 1.147 | 0.939–1.403 | 0.179 |
Lead adhesion to heart structures (any) | 1.699 | 1.252–2.307 | <0.001 | 1.045 | 0.658–1.660 | 0.851 |
Long Term and 30-Days Survival after TLE | Flying Ghosts (Ghosts Shifting Spontaneously to Pulmonary Vascular Bed) | Stable Ghosts (Ghosts Remaining Attached to Cardiovascular Wall) | Ghosts Absent during and after TLE |
---|---|---|---|
Group/number of patients | 1: N = 171 | 2: N = 322 | 3: N = 610 |
Long-term survival of entire group of patients after TLE during mean 1264 ± 644.7 (2–2466) days follow-up. Log rank p for all model = 0.186 | |||
Follow-up (mean ± SD) [days] | 1048 ± 417.5 p < 0.001 | 1511 ± 588.0 p = 0.567 | 1544 ± 555.0 p < 0.001 |
Alive during follow-up (entire group) (n, %) | 143 (83.63) Log rank test p = 0.914 | 242 (75.16) Log rank test p = 0.121 | 437 (71.64) Log rank test p = 0.202 |
Died during follow-up (entire group) (n, %) | 28 (16.37) Log rank test p = 0.914 | 80 (24.84) Log rank test p = 0.121 | 173 (28.36) Log rank test p = 0.202 |
Long-term survival after TLE in the subgroup of non-infectious and infectious patients. Log rank p for all model = 0.036 | |||
Non-infectious; died/alive (n, %) | 19/131 (12.67) Log rank test p = 0.430 | 41/200 (17.01) Log rank test p = 0.014 | 114/360 (24.05) Log rank test p = 0.259 |
Infectious (all); died/alive (n, %) | 9/12 (42,86) Chi2 (vs. non-infectious) p = 0.001 | 39/42 (48.15) Chi2 (vs. non-infectious) p < 0.001 | 59/77 (43.38) Chi2 (vs. non-infectious) p < 0.001 |
Long-term survival after TLE in subgroup of patients with pocket infection. Log rank p for all model = 0.786 | |||
Local (pocket) infection; died/alive (n, %) | 2/4 (33.33) Log rank test p = 1.000 | 8/10 (44.44) Log rank test p = 0.463 | 11/27 (28.95) Log rank test p = 0.917 |
Long term survival after TLE in subgroup of patients with systemic. Log rank p for all model = 0.948 | |||
Systemic infection; died/alive (n, %) | 7/8 (46.67) Log rank test p = 0.789 | 31/32 (49.21) Log rank test p = 0.839 | 48/50 (48.98) Log rank test p = 0.812 |
30-days survival after TLE in entire group of patients | |||
Entire group; died/alive (n, %) | 2/169 (1.17) Chi2 (1 vs. 2) p = 0.660 | 7/315 (2.17) Chi2 (2 vs. 32) p = 0.747 | 10/600 (1.64) Chi2 (1 vs. 3) p = 0.929 |
30-days survival after TLE in subgroup of non-infectious patients | |||
Non-infectious; died/alive (n, %) | 2/148 (1.33) Chi2 (1 vs. 2) p = 0.972 | 2/239 (0.83) Chi2 (2 vs. 3) p = 0.679 | 4/470 (0.84) Chi2 (1 vs. 3) p = 0.956 |
Infectious (all); died/alive (n, %) | 0/21 (0.00) Chi2 (vs. non-infectious) p = 0.581 | 5/76 (6.17) Chi2 (vs. non-infectious) p = 0.016 | 6/130 (4.41) Chi2 (vs. non-infectious) p = 0.012 |
30-days survival after TLE in subgroup of patients with pocket infection | |||
Local (pocket) infection; died/alive (n, %) | 0/6 (0.00) | 0/18 (0.00) | 0/38 (0.00) |
Long term survival after TLE in subgroup of patients with systemic infection | |||
Systemic infection; died/alive (n, %) | 0/15 (0.00) Chi2 (1 vs. 2) p = 0.588 | 5/58 (7.94) Chi2 (2 vs. 3) p = 0.900 | 6/92 (6.12) Chi2 (1 vs. 3) p = 0.714 |
Univariable Cox Regression | Multivariable Cox Regression | |||||
---|---|---|---|---|---|---|
HR | 95% | p | HR | 95% | p | |
All patients | ||||||
Female gender | 0.441 | 0.336–0.579 | <0.001 | 0.621 | 0.463–0.833 | <0.001 |
Patient age during TLE [by year] | 1.049 | 1.038–1.061 | <0.001 | 1.040 | 1.025–1.054 | <0.001 |
NYHA FC class [by one] | 2.914 | 2.410–3.523 | <0.001 | 1.526 | 1.197–1.946 | <0.001 |
LVEF [by 1p%] | 0.966 | 0.958–0.973 | <0.001 | 0.987 | 0.981–0.978 | 0.009 |
Renal failure (any) | 3.269 | 2.587–4.131 | <0.001 | 1.599 | 1.243–2.058 | 0.001 |
Ischemic heart disease | 1.457 | 1.125–1.887 | 0.004 | 1.014 | 0.758–1.355 | 0.927 |
Permanent atrial fibrillation | 2.372 | 1.866–3.015 | <0.001 | 1.443 | 1.122–1.856 | 0.004 |
Charlson comorbidity index | 1.142 | 1.111–1.174 | <0.001 | 1.044 | 1.010–1.080 | 0.012 |
Flying ghosts (1st group) | 0.795 | 0.537–1.178 | 0.252 | |||
Stable ghosts (2nd group) | 0.881 | 0.680–1.141 | 0.336 | |||
Ghosts absent (3rd group) | 1.223 | 0.962–1.555 | 0.100 | |||
ICD presence before TLE | 1.156 | 0.884–1.512 | 0.292 | |||
Device type: CRTP/CRTD | 3.125 | 2.382–4.100 | <0.001 | 1.702 | 1.248–2.322 | <0.001 |
Systemic infection | 2.854 | 2.220–3.667 | <0.001 | 1.894 | 1.460–2.457 | <0.001 |
Isolated pocket infection | 1.281 | 0.829–1.979 | 0.265 | |||
Infectious patients | ||||||
Female gender | 0.485 | 0.301–0.780 | 0.003 | 0.578 | 0.347–0.964 | 0.036 |
Patient age during TLE [by year] | 1.027 | 1.009–1.045 | 0.003 | 1.037 | 1.014–1.061 | 0.002 |
NYHA FC class [by one] | 2.278 | 1.687–3.075 | <0.001 | 1.659 | 1.118–2.462 | 0.012 |
LVEF [by 1p%] | 0.969 | 0.957–0.981 | <0.001 | 0.988 | 0.972–1.004 | 0.133 |
Renal failure (any) | 2.512 | 1.729–3.649 | <0.001 | 1.686 | 1.136–2.503 | 0.009 |
Ischemic heart disease | 0.938 | 0.620–1.421 | 0.764 | |||
Permanent atrial fibrillation | 1.642 | 1.106–2.438 | 0.014 | 1.010 | 0.657–1.552 | 0.965 |
Charlson comorbidity index | 1.096 | 1.047–1.147 | <0.001 | 1.025 | 0.972–1.082 | 0.363 |
Flying ghosts (1st group) | 1.089 | 0.548–2.163 | 0.807 | |||
Stable ghosts (2nd group) | 1.041 | 0.705–1.536 | 0.841 | |||
Ghosts absent (3rd group) | 0.940 | 0.645–1.369 | 0.747 | |||
Device type: ICD | 1.018 | 0.666–1.556 | 0.935 | |||
Device type: CRTP/CRTD | 2.783 | 1.861–4.161 | <0.001 | 1.766 | 1.087–2.868 | 0.022 |
Isolated pocket infection | 0.560 | 0.351–0.894 | 0.015 | 1.083 | 0.581–2.018 | 0.801 |
Vegetations presence | 1.620 | 1.094–2.399 | 0.016 | 1.405 | 0.835–2.365 | 0.201 |
Non-infectious patients | ||||||
Female gender | 0.478 | 0.342–0.669 | <0.001 | 0.638 | 0.443–0.919 | 0.016 |
Patient age during TLE [by year] | 1.056 | 1.040–1.071 | <0.001 | 1.043 | 1.024–1.062 | 0.000 |
NYHA FC class [by one] | 3.140 | 2.439–4.043 | <0.001 | 1.619 | 1.165–2.249 | 0.004 |
LVEF [by 1p%] | 0.965 | 0.956–0.975 | <0.001 | 0.988 | 0.975–1.000 | 0.048 |
Renal failure (any) | 3.356 | 2.483–4.535 | <0.001 | 1.489 | 1.072–2.068 | 0.017 |
Ischemic heart disease | 1.602 | 1.151–2.230 | 0.005 | 0.882 | 0.618–1.258 | 0.488 |
Permanent atrial fibrillation | 2.815 | 2.078–3.814 | <0.001 | 1.693 | 1.236–2.320 | 0.001 |
Charlson comorbidity index | 1.148 | 1.108–1.190 | <0.001 | 1.058 | 1.013–1.105 | 0.011 |
Flying ghosts (1st group) | 0.822 | 0.509–1.330 | 0.425 | |||
Stable ghosts (2nd group) | 0.721 | 0.508–1.024 | 0.068 | 1.103 | 0.633–1.923 | 0.728 |
Ghosts absent (3rd group) | 1.428 | 1.043–1.954 | 0.026 | 1.352 | 0.821–2.226 | 0.236 |
Device type: ICD | 1.162 | 0.820–1.645 | 0.398 | |||
Device type: CRTP/CRTD | 2.758 | 1.895–4.015 | <0.001 | 1.684 | 1.126–2.520 | 0.011 |
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Nowosielecka, D.; Jacheć, W.; Polewczyk, A.; Tułecki, Ł.; Stefańczyk, P.; Kutarski, A. “Ghost”, a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance. Int. J. Environ. Res. Public Health 2022, 19, 12542. https://doi.org/10.3390/ijerph191912542
Nowosielecka D, Jacheć W, Polewczyk A, Tułecki Ł, Stefańczyk P, Kutarski A. “Ghost”, a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance. International Journal of Environmental Research and Public Health. 2022; 19(19):12542. https://doi.org/10.3390/ijerph191912542
Chicago/Turabian StyleNowosielecka, Dorota, Wojciech Jacheć, Anna Polewczyk, Łukasz Tułecki, Paweł Stefańczyk, and Andrzej Kutarski. 2022. "“Ghost”, a Well-Known but Not Fully Explained Echocardiographic Finding during Transvenous Lead Extraction: Clinical Significance" International Journal of Environmental Research and Public Health 19, no. 19: 12542. https://doi.org/10.3390/ijerph191912542