Ann Thorac Surg 2002;73:1623-1626
© 2002 The Society of Thoracic Surgeons
Case report
Late presentation of retained intracardiac ice pick with papillary muscle injury
Malek G. Massad, MD*a,
Fadi Khoury, MDa,
Alexander Evans, MDa,
Christian Sirois, MDa,
Rabih Chaer, MDa,
Yaulaunda Thomas, MDa,
Norman J. Snow, MDa,
Joan Briller, MDb,
Alexander S. Geha, MDa
a Division of Cardiothoracic Surgery, The University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
b Division of Cardiology, The University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
Accepted for publication September 9, 2001.
* Address reprint requests to Dr Massad, Division of Cardiothoracic Surgery, The University of Illinois at Chicago, 840 S. Wood St, CSB Suite 417 (MC 958), Chicago, IL 60612, USA
e-mail: mmassad{at}uic.edu
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Abstract
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An unusual case of a penetrating intracardiac injury is described in a 16-year-old boy who presented with a retained 14-cm segment of an ice pick that went unnoticed by the patient for 4 days. The ice pick had lacerated the anterior papillary muscle of the left ventricle causing avulsion of its tip and prolapse of the anterior leaflet of the mitral valve resulting in severe mitral regurgitation. The urgency for surgical correction of the traumatic mitral valve injury at the time of extraction of the intracardiac foreign body through a single-stage approach versus a two-stage approach is discussed.
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Introduction
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Penetrating cardiac injuries among civilians have been reported to occur approximately once per 100,000 man years and account for 1 per 210 admissions to a regional Level I trauma center [1]. Retained projectile missiles such as bullets, shrapnel, nails, and wooden-tipped arrows have been reported [2–4]. Likewise, retained nonprojectile objects resulting from stab wound injuries such as needles and knives have also been described [5, 6]. A metaanalysis performed on a population-based cohort showed an overall survival rate of 19%. Interestingly, intracardiac defects caused by a retained ice pick have not been yet reported. In this communication, we describe the successful management of an unusual case of a penetrating intracardiac injury in a 16-year-old boy who presented with a retained segment of an ice pick that went unnoticed by the patient for 4 days.
A 16-year-old boy walked to the Emergency Department at the University of Illinois Hospital and Medical Center 4 days after he was involved in a street fight. The patient reported that he was assaulted by members of a street gang. However, he did not recall any weapons or sharp objects. The patient went home following the incident. However, he continued to have pain over his back exacerbated by movement and associated with feverishness that prompted his mother to bring him to the hospital. He was tolerating his diet well with no evidence of dysphagia or aspiration upon swallowing. On arrival to the Emergency Department, the patient was mobile but his activity was limited by the sharp back pain and by chest discomfort exacerbated by breathing. On physical examination, his blood pressure was 110/70 mm Hg; he had a sinus tachycardia with a heart rate of 120 beats per minute and a respiratory rate of 20 breaths per minute. His tympanic temperature was 100°F. Chest and trunk exam showed evidence of a small skin laceration (about 1 x 1 centimeter in diameter) over the left paraspinal area at the level of the fourth thoracic vertebra. His lung exam showed clear and equal breath sounds bilaterally. There was no evidence of crepitation or subcutaneous emphysema to suggest a tracheobronchial injury. Auscultation of the heart showed distant heart sounds with a grade 4/6 systolic murmur heard best along the left lower sternal border. The remainder of his examination was otherwise normal. Workup included a complete blood count that showed a hemoglobin level of 14 mg/dl, a hematocrit of 45%, a white blood cell count of 13,600 cells/mm3 and serum electrolytes that were normal. A plain chest radiogram was then performed and showed a long sharp object overlying the cardiac silhouette on the posteroanterior view (Fig 1A).
The lateral projection confirmed the presence of a long retained segment of an ice pick in the left pleural cavity penetrating the left lung into the heart (Fig 1B). There was no evidence of hemothorax, pulmonary contusion, or edema. Subsequent computerized tomography of the chest confirmed the intracardiac location of the ice pick with the tip located in the right ventricular cavity.
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Fig 1. (A) Plain chest radiography showing a long sharp object overlying the cardiac shadow on the posteroanterior view. (B) The lateral view confirms presence of a long retained segment of an ice pick within the cardiac chambers.
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The patient was admitted to the Intensive Care Unit with stable hemodynamics. He continued to have sinus tachycardia despite intravenous fluids and was noted to develop frequent premature ventricular contractions upon movement in bed suggesting local irritation of the myocardium by the intracardiac foreign object. After obtaining blood cultures (that latter showed no growth of bacteria), he was placed on broad spectrum intravenous antibiotic coverage (cefuroxime 1.5 gm every 12 hours). A transthoracic echocardiogram with Doppler imaging was initially obtained; it showed evidence of a small pericardial effusion and confirmed the presence of the foreign object penetrating the heart through the lateral wall of the left ventricle across the ventricular septum and into the right ventricular cavity. There was evidence of severe mitral regurgitation on echocardiography with prolapse of the anterior leaflet and a flail chordo-papillary segment, all suggesting injury to the mitral valve apparatus by the ice pick. There was no evidence of any other valvular abnormality. A bubble study with agitated saline injected into the right heart did not demonstrate any evidence of shunting to the left heart through the atrial or ventricular septum. A Swan-Ganz catheter was then placed through the right internal jugular vein. The right atrial pressure was 12 mm Hg, and pulmonary artery pressures were 30/18 mm Hg with a mean pulmonary pressure of 22 mm Hg (wedge pressure of 18 mm Hg). Blood oxygen saturation measurements failed to show any significant step-up in blood oxygen saturation between the right atrium and the pulmonary artery to suggest a septal defect.
The patient was taken to the operating room where flexible fiberoptic bronchoscopy and esophagoscopy were performed and ruled out presence of any tracheobronchial or esophageal injury. Subsequently, the patient was anesthetized and intubated with a selective double lumen endobronchial tube. A left lateral thoracotomy was then performed through the fourth intercostal space. Upon deflating the left lung and exposing the left pleural cavity, the base of the ice pick could be seen penetrating through a contused area in the superior (apical) segment of the left lower lobe just below the hilum of the left lung. There was a small amount of blood in the pleural cavity. The foreign object had traversed the pericardium into the ventricular chambers. The pericardium was opened through a longitudinal incision posterior to the phrenic nerve. Approximately 200 ml of blood was drained from the pericardium after which it became apparent that the pick had entered the lateral wall of the left ventricle just below the atrioventricular groove sparing the left atrial appendage and the circumflex coronary artery. Although the tip of the ice pick could be felt by gentle palpation of the right ventricular apex, there was no evidence of penetration of the right ventricular free wall. A 3-0 pledgetted polypropylene suture was then placed around the cardiac entry site and the retained segment of the ice pick that measured 14 cm in length (Fig 2A)
was pulled back along the course of its trajectory to avoid further damage to other cardiac structures. The intracardiac entry point was then secured. Bleeding from the left lung was controlled with the use of suture ligatures.
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Fig 2. (A) A 14-cm long segment of an ice pick extracted from the left hilum and cardiac chambers. (B) Intraoperative view of the mitral valve apparatus showing avulsion of the tip of the anterior papillary muscle that was flail attached only to the edge of the anterior leaflet. The distal segment of the trunk of the anterior papillary muscle is also shown.
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The patient recovered well from his initial operation. A repeat transesophageal echocardiogram was performed 1 week after the injury and confirmed earlier findings of severe mitral regurgitation with flail chordae, but showed no evidence of a residual traumatic ventricular septal defect with an agitated saline study, suggesting the possibility of spontaneous closure. That was also confirmed by the absence of blood oxygen saturation step-up assayed through a Swan-Ganz catheter. One week after his thoracotomy, the patient was returned to the operating room for repair of his mitral valve apparatus through a median sternotomy. After maintaining cardioplegic arrest, the mitral valve was exposed through a left atriotomy incision. The posterior leaflet and chordae looked normal. The anterior leaflet was also intact. The tip of the anterior papillary muscle was avulsed and was attached only to the edge of the anterior leaflet through its chordae (Fig 2B). The proximal segment of the trunk of the anterior papillary muscle was contused and friable, though the remaining part of the trunk looked healthy. The transected tip of the papillary muscle was excised along with its flail chordae. The prolapsed mid-segment of the anterior leaflet was then tacked back to the papillary muscle trunk using two 4-0 pledgeted Gore-Tex sutures (W. L. Gore & Associates, Flagstaff, AZ), in essence replacing the severed chordal attachment. Satisfactory results of the repair were confirmed with intraoperative transesophageal echocardiography. The postoperative course was uneventful. The patient was discharged home and continues to do well at follow-up without dyspnea or limitation of activity.
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Comment
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Residual or delayed lesions from penetrating cardiac wounds include cardiac tamponade, septal defect, ventricular wall hematoma, pseudoaneurysm, thrombus formation, clot or foreign body embolization, conduction system injury, and valvular injury including leaflet perforation with or without chordal disruption. Injury to the papillary muscle of the left ventricle is quite uncommon. The patient may present either with acute symptoms of mitral regurgitation in the case of an avulsion injury such as in the case described, or may present with delayed sequelae when the papillary muscle is severely bruised. In addition, small penetrating injuries to the ventricular septum, and especially those located in the muscular septum, such as a slit-like injury caused by an ice pick have been occasionally reported to close spontaneously [7]. This has prompted several authors to recommend waiting for a period of up to 6 months or even more before attempting surgical closure of this secondary injury, particularly if the patient was stable at initial presentation and the shunt is small [8]. In view of these observations, it is justifiable to stage the operative intervention in the stable patient with no heart failure symptoms in order to initially address the primary life-threatening injury. Elective surgical repair of the residual defect is then undertaken at a later setting.
Retained foreign objects from penetrating injuries that remain in contact with blood are associated with a higher incidence of infections as a result of the contaminated wounding object. Bacterial endocarditis may even occur early after the injury. Hence, it is important to administer broad spectrum intravenous antibiotics empirically at the time of presentation and after the appropriate cultures are obtained. This is especially true in patients who present late after the injury.
Because of the posterior entry and the oblique trajectory of the foreign body and the intracardiac location of its tip, and since the patient was hemodynamically stable with no signs and symptoms of heart failure or pulmonary edema due to mitral insufficiency, we decided to stage the operation by initially approaching the patient through a left thoracotomy to extract the long foreign object along its trajectory and later addressing the papillary muscle injury through a median sternotomy on cardiopulmonary bypass. This approach was adopted in order to minimize the operative risk by initially avoiding full heparinization of the patient for cardiopulmonary bypass particularly in the presence of lung injury. Furthermore, it was felt that a one-stage approach through a median sternotomy to extract the ice pick through an anterior cardiotomy and repair the papillary muscle on cardiopulmonary bypass would have probably carried a higher risk of operative morbidity and mortality, as in-line extraction to minimize collateral damage would have been difficult if not impossible through the anterior sternotomy.
In this particular case, a transthoracic echocardiogram was initially obtained rather than a transesophageal echocardiogram because an esophageal injury had not been ruled out at the time of presentation, and because of concern that manipulation of the transesophageal probe might dislodge the sharp intracardiac foreign object thereby complicating the injury by causing further damage to the heart and mediastinal structures, and also by creating more bleeding. However, in the absence of esophageal injury or a retained sharp object, transesophageal echocardiography becomes mandatory even in the presence of a negative transthoracic echocardiogram, as it can delineate the intracardiac injuries more precisely. Transesophageal echocardiography continues to be a safe, accurate, and highly valuable tool in the evaluation of patients with trauma to the heart or mediastinal structures.
The interest in this case lies in the fact that penetrating cardiac injuries with retained foreign objects as long as a 14-cm ice pick may go unnoticed by the patient for days with little or no symptoms. Radiographic evaluation becomes mandatory following blunt or penetrating chest trauma in unsuspecting patients with unexplained pleuritic chest pain and tachycardia. Routine late follow-up and assessment of these patients should include serial echocardiographic imaging to evaluate for any late sequelae that develop following the cardiac injury.
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References
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Abstract
Introduction
