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Ann Thorac Surg 2001;72:668
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, University Hospital, Linkoping, S-58185, Sweden
e-mail: igorkonst{at}hotmail.com
To the Editor
We read with interest the recent report of Venissac and colleagues [1] describing a rare, yet important issue of intrathoracic migration of Kirschner pins. The authors reported two cases of Kirschner pin migration from the left clavicle to the anterior mediastinum. In the first case, the broken pin was removed by video-assisted thoracic surgery (VATS) through the right chest. In the second case, the tip of the pin entered the wall of the extrapericardial ascending aorta. Although VATS was attempted through the right chest, the pin could not be identified and was not found after "conversion" to open thoracotomy. It was, however, successfully removed through a median sternotomy incision. Others have also described similar cases in which median sternotomy was necessary after an unsuccessful thoracotomy for a Kirschner wire that had migrated into the pulmonary artery [2].
It was gratifying to see that the skillful application of VATS by Venissac and coworkers spared the patient from unnecessary thoracotomy. We would like to voice our support of the VATS approach applied by the authors. We have encountered a case of a 2.5-cm-long Kirschner pin migration into the right ventricle and outlined the guidelines for intrapericardial needle removal by VATS [3]. Our patient developed effusive pericarditis. Echocardiography demonstrated a needle moving with the heart beat inside the right ventricle. There were no vegetations or thrombi. We suspected that the needle had perforated the myocardium and had caused mechanical irritation of the pericardium. Because of the evidence of pericardial irritation, it was likely that the tip of the needle might be visualized on the heart surface, making removal of the needle by VATS a possibility. Therefore, VATS was performed through the right thoracic cavity. The pericardium was opened and the exact position of the needle was determined with a combination of VATS and radiologic images. However, despite meticulous examination of the cardiac surface, the tip of the needle could not be visualized. Median sternotomy was performed. The needle was immobilized and pressed against the endocardium by one large buttressed suture applied transmyocardially to the beating heart. The needle was then removed through a small incision.
We believe that VATS is safe and useful procedure for needle removal from the mediastinum and pleural and pericardial cavities. If the needle is located in the mediastinum and cannot be found by VATS, it is unlikely to be found through a thoracotomy either. We believe that in such cases thoracotomy should not be performed, but rather the needle should be removed through the median sternotomy.
VATS must, however, be applied judiciously. If the needle is visualized in the pleural or pericardial cavity but has penetrated into the myocardium or great vessel it can be removed by minithoracotomy or pericardiotomy, with VATS guidance. In these cases VATS should be performed only by an experienced cardiothoracic surgeon with expertise of converting the technique into an open procedure and instituting cardiopulmonary bypass if indicated.
References
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