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Ann Thorac Surg 1999;68:291-292
© 1999 The Society of Thoracic Surgeons

Correspondence

Foreign bodies in the heart: surgical or medical therapy?

Guglielmo M. Actis Dato, MDa, Enrico Aidala, MDa, Giuseppe F. Zattera, MDa

a Italian Institution of Cardiac Surgery, Via Genova, 4, 10126 Turin, Italy

To the Editor

It was very interesting to read the case report by LeMaire and colleagues [1] regarding a needle migration to the right heart after an intravenous injection. Recently, we reviewed our own experience regarding the treatment of foreign bodies migrated in the heart from the vascular system or after traumatic injury [2, 3]. From 1955 to 1989 we observed 12 patients in which a foreign body was localized into or near to the heart (Table 1). In particular, we observed 3 patients of needle localized in the heart; therefore, we will point out some aspect of this particular and uncommon condition.


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  		Table 1. Foreign Bodies Localized in the Heart (1955–1989)

 
In our experience the exact mechanism of needle localization in the heart was not completely clear. In fact in 1 patient (Fig 1) the needle arrived just to the pulmonary artery, probably from the vascular system after a peripheral penetration occurred accidentally. The needle in this patient did not produce particular symptoms and for this reason diagnosis was made many years later after an occasional chest roentgenogram. No operation was necessary and at present, the patient is alive and in good clinical conditions. In 2 additional patients the needle penetration occurred in childhood (Fig 2) and in such cases a possible explanation was a direct penetration from the thoracic cage to the cardiac muscle. The diagnosis was made by chest roentgenogram in the presence of recurrent fever and a surgical removal was done.



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  		Fig 1. Needle penetrating the vascular system and localized in the pulmonary artery. Note that needle fragmentation occurred during the years (not removed).

 


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  		Fig 2. Needle localized in the left ventricle of an infant 2.5-year-old with recurrent fever (removed).

 
It is important to determine the exact location of the foreign bodies before the operation to choose the more appropriate surgical strategy. At the present time a transthoracic echocardiography and a computed tomographic scan are mandatory to have a correct diagnosis and an exact localization of the foreign body. In our series most patients were operated during the 1960s and the 1970s, when echocardiography and other diagnostic tools were unavailable, therefore a chest roentgenogram in two or four projections was enough to localize and remove it. We believe that at present an intraoperative transesophageal echocardiography can be helpful during the surgical removal; in fact, the visualization of the foreign body can be difficult because bleeding, presence of pericardial adherence, or, in case of localization, in the cardiac muscle or into the heart chambers.

The best way to remove a foreign body, when a surgical treatment is necessary in our experience, was a left thoracotomy with no need of cardiopulmonary bypass, except in 2 patients who received a median sternotomy and cardiopulmonary bypass (valvothomy ring and rotating sew fragment). In particular the needle removal was possible with no need for cardiopulmonary bypass.

We strongly agree with the recommendations of LeMaire and colleagues regarding the medical management of patients with foreign bodies: "if a foreign body is small and smooth, if the risk of contamination is minimal and if the symptoms are absent there is no indication to remove it."

References

  1. LeMaire S.A., Wall M.J., Mattox K.L. Needle embolus causing cardiac puncture and chronic constrictive pericarditis. Ann Thorac Surg 1998;65:1786-1787.[Abstract/Free Full Text]
  2. Actis Dato G.M., Actis Dato A., Jr, Pellegrino A., Nudi F., Persiani M. Trattamento di corpi estranei intracardiaci post-traumatici o iatrogeni. Il Cuore 1991;8:635-644.
  3. Ottino G., Zattera G., Lamarca S., et al. Penetrating wound of the right ventricle with intracardiac retention of the foreign body. Thorac Cardiovasc Surg 1989;37:264-266.[Medline]

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Reply
Scott A. LeMaire, Matthew J. Wall, Jr, and Kenneth L. Mattox
Ann. Thorac. Surg. 1999 68: 292. [Extract] [Full Text] [PDF]



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