Ann Thorac Surg 2005;80:322-324
© 2005 The Society of Thoracic Surgeons
Case report
Tricuspid Valve Incompetence Caused by an Intracardiac Needle-Like Foreign Body
Toshiro Kobayashi, MD*,
Kenji Hayashi, MD,
Kensuke Sakata, MD,
Yurio Kobayashi, MD
Department of Cardiovascular Surgery, Saiseikai Shimonoseki General Hospital, Yamaguchi, Japan
Accepted for publication January 22, 2004.
* Address reprint requests to Dr Takano, Department of Surgery E-1, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan (Email: kobaling{at}tf6.so-net.ne.jp).
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Abstract
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We report a rare case of tricuspid valve incompetence caused by a needle-like foreign body with an unknown route of invasion. A 55-year-old woman who had suffered from chronic heart failure for more than 25 years was diagnosed as having Ebstein’s anomaly after a transthoracic echocardiogram with Doppler imaging showed severe tricuspid regurgitation and displacement of the septal leaflet toward the right ventricle inlet. Surgery revealed a foreign body attached to the tricuspid valve, causing regurgitation. Valve replacement was performed and the patient’s condition improved remarkably thereafter.
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Introduction
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We report a case of chronic heart failure resulting from tricuspid valve regurgitation caused by an intracardiac foreign body in the right ventricle that had been attached to the tricuspid valve for many years. The initial diagnosis was congenital Ebstein’s anomaly because echocardiography showed displacement of the septal leaflet to a position below the annulus fibrosus and severe tricuspid regurgitation. The patient’s condition improved dramatically after a successful tricuspid valve replacement.
A 55-year-old woman with a 25-year history of cardiac symptoms was admitted to our hospital with facial and pedal edema. When she was 30 years old, cardiomegaly had been diagnosed and she was starting to experience episodes of spontaneous palpitation, but no medical treatment was given. At the age of 47 years, she was experiencing frequent and prolonged palpitations at work and was admitted to our hospital for investigation. Echocardiography showed tricuspid valve regurgitation and displacement of the septal leaflet to a position below the annulus fibrosus, and a diagnosis of Ebstein’s anomaly was made. She was treated medically but stopped taking the medication herself.
On physical examination, her blood pressure was 106/60 mm Hg and she had atrial fibrillation, with a mean heart rate of 70 beats per minute. Her lungs were clear with equal air entry and a respiratory rate of 13 breaths per minute. Auscultation of the heart showed a grade 3/6 systolic murmur, which was loudest along the left lower sternal border. A plain chest roentgenogram showed marked cardiomegaly and a dilated right atrium. A short, sharp object was seen overlying the cardiac silhouette on the posteroanterior and lateral views (Fig 1). A transthoracic echocardiogram with Doppler imaging showed severe tricuspid regurgitation and displacement of the septal leaflet to below the annulus fibrosus. Another view of the echocardiogram showed a high-density object. Surgery was indicated because chronic heart failure caused by tricuspid regurgitation is resistant to medical treatment.
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Fig 1. (A) Plain chest roentgenogram shows severe cardiomegaly and a dilated right atrium. (B) Transthoracic echocardiogram shows displacement of the septal leaflet to a position below the annulus fibrosus. (LA = left atrium; LV = left ventricle; MV = mitral valve; RA = right atrium; RV = right ventricle; TV = tricuspid valve.)
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A median sternotomy was performed that revealed slight effusion but no adhesion between the pericardium and the heart. The right atrium and ventricle were very enlarged, but there was no apparent atrialized ventricle. The patient was placed on cardiopulmonary bypass, and after cardioplegic arrest, the right cardiac space was exposed through a right atriotomy incision. No fossa ovalis or atrial septal defect was detected in the atrial septum. A foreign body was attached to the tricuspid anterior leaflet, extending from the right atrial space, crossing it, and adhering to the anterior papillary muscle (Fig 2). The foreign body was black and rust colored, with the appearance of a needle, which had spherical parts at both ends. It was approximately 2.5 cm long and hard but fragile. The tissue inflammatory changes caused by the foreign body resulted in shortening of the chordae tendon and adhesion between the anterior leaflet and anterior papillary muscle. The shortened chordae of the septal leaflet caused restriction of the leaflet movement and seemed to be adhered to the septum. The anterior leaflet development was poor, with partially elongated chordae. These configurations, especially the adhesion of the septal leaflet to the ventricular septum, had resulted in the echocardiographic diagnosis of Ebstein’s anomaly. There were no leaflets located in the ordinal annulus or atrialized ventricle.
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Fig 2. (A) Operative findings through a right atriotomy incision. A foreign body was attached to tricuspid anterior leaflet, extending from the right atrial space, crossing it, and adhering to the anterior papillary muscle. (B) The needle-like foreign body removed from right cardiac chamber.
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After removing the foreign body, we repaired the anterior leaflet. Annular dilatation of the tricuspid valve was observed, and annuloplasty was performed by the De’Vega method. The anterior and posterior leaflets were sutured in each commissure. Because tricuspid valve regurgitation persisted after the valvoplasty, valve replacement using a 33-mm Carpenter-Edwards prosthetic valve was necessary to prevent regurgitation. The patient had an uneventful postoperative recovery.
Microscopic examination revealed only that the foreign body was a metallic object.
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Comment
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Our patient presented with the clinical features of chronic heart failure caused by tricuspid regurgitation, and we diagnosed Ebstein’s anomaly by the echocardiographic findings. However, an operation revealed a foreign body attached to tricuspid anterior leaflet that was causing the tricuspid regurgitation. The tissue inflammatory reaction resulted in a shortened chordae tendon caused by restriction of the septal leaflet movement. Retrospectively, the foreign body could be seen on the plain chest roentgenogram as a short, sharp object, and a high-density object was also seen on the echocardiogram. The foreign body was approximately 2.5 cm long and narrow, with spherical parts at both ends. It was hard but fragile, and based on the characteristic configuration and microscopic findings, it might have been a pin or a needle. There are two possible routes for a needle to reach the heart: by a transvenous route and by direct injury to the chest wall via the heart [1–4]. We asked the patient several times whether she could recall any traumatic injection or needle-like injury involving a needle, pin, or another sharp metal object in which a small splinter of metal may have penetrated the skin, but she could not. Therefore, the route of foreign body injury remains unknown. Kenaan and colleagues [5] reported a similar case involving a 59-year-old woman in whom a large wooden splinter lodged in the right ventricle for 54 years led to a diagnosis of a double-chambered right ventricle and tricuspid incompetence. The myocardial and endocardial fibrosis and massive fibrosus tissue reaction led to these pathologic processes.
In summary, this report describes an unusual and interesting case of tricuspid incompetence caused by an intracardiac foreign body, possibly a pin or needle, but the route of injury could not be determined.
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References
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- Hermoni Y, Engel PJ, Gallant TE. Sequelae of injury to the heart caused by multiple needles J Am Coll Cardiol 1986;8:1226-1231.[Abstract]
- Jamilla FP, Casey LC. Self-inflicted intramyocardial injury with a sewing needlea rare cause of pneumothorax. Chest 1998;113:531-534.[Abstract/Free Full Text]
- Tveskov C, Angelo-Nielsen K. Late cardiac tamponade after self-injury with a needle Eur Heart J 1993;14:1578.[Abstract/Free Full Text]
- Wagner RB. Massive hemothorax secondary to foreign body and CPR Ann Thorac Surg 1995;59:1241-1242.[Free Full Text]
- Kenaan G, Kay JH, Redington JV, et al. Intracardiac foreign body simulating double-chamber right ventricle Am J Cardiol 1973;31:781-784.[Medline]
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Abstract
Introduction
