Paradoxical Embolism from a Migrated Right Atrial “Lead Ghost” through an Unrecognized Patent Foramen Ovale after Cardiac Resynchronization Therapy–Defibrillator Lead Extraction: a Case Report

Abstract Background A “lead ghost” is a fibrotic or thrombotic cast that remains after transvenous lead extraction (TLE) and typically resides within the right heart. This case describes a paradoxical embolism through an unrecognized patent foramen ovale (PFO), most likely due to a transient right-to-left shunt that allowed the “lead ghost” to enter the systemic circulation. Case Summary A 55-year-old man with ischaemic cardiomyopathy (ICM) underwent cardiac resynchronization therapy–defibrillator (CRT-D) lead extraction for right-ventricular (RV) lead fracture. Intraoperative transoesophageal echocardiography (TOE) revealed a 3.5-cm fibrous cast detaching from the right atrium (RA) and traversing an unrecognized PFO into the left atrium (LA). Surgical removal of the migrated cast with concomitant PFO closure was performed approximately 48 hours after extraction following multidisciplinary evaluation, as it remained unchanged in size despite therapeutic anticoagulation and a device-pocket hematoma. Approximately 24 hours after surgery, he developed expressive aphasia; brain computed tomography (CT) confirmed a left middle cerebral artery (MCA) territory infarct without large-vessel occlusion. He was discharged to neuro-rehabilitation with mild residual aphasia. Discussion This case highlights paradoxical embolism from a migrated RA “lead ghost” through a PFO, a rare but high-impact complication of TLE. Transient right-to-left shunting may occur when RA pressure exceeds LA pressure during procedural conditions (e.g., positive-pressure ventilation or Valsalva). In this case, the PFO was not appreciated on initial intra-procedural imaging; subsequent echocardiography, including agitated-saline study with Valsalva, demonstrated right-to-left shunting. Definitive management was achieved with surgical extraction of the migrated cast and concomitant PFO closure.