Ann Thorac Surg 2006;81:335-336
© 2006 The Society of Thoracic Surgeons
Case report
A Piece of Glass in the Heart
Xiubin Yang, MD
*
,
Xiangdong Shen, MD
Department of Cardiovascular Surgery, Cardiovascular Institute and Fu Wai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
Accepted for publication October 5, 2004.
* Address correspondence to Dr Yang, Fu Wai Hospital, Bei Li Shi Lu 167, Beijing 100037, China (Email: xiubinyang{at}yahoo.com).
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Abstract
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Most posttraumatic foreign bodies are metal objects in the heart, such as bullets and needles; nonmetal objects are very rare. We now report a case in which a piece of glass entered a girl's heart from an injury to the right side of her neck. Six months later, we successfully removed the glass shard from the anterior wall of the right ventricle.
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Introduction
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Recently, we treated a patient who had a foreign body in her heart. We removed a 4.5 cm dagger-shaped glass shard from her heart 6 months after the injury. The patient was wounded in the right side of her neck by broken glass but had no chest injury.
A 6-year-old girl was sent to the emergency room for a wound from a broken door in the right side of her neck. At admission, the patient had serious bleeding, but surgeons found nothing in the wound and sutured it closed directly after disinfection and debridement.
The next morning, the patient had a pectoral pain and dyspnea, and 5 days later she was referred to a local children's hospital. She had tachycardia and tachypnea with shallow respiration. On physical examination, her heart rate was 120 to 140 beats per minute, and her blood pressure was 96/60 mm Hg. No heart murmur or pericardial friction rub was heard, but heart sounds were faint. Blood hemoglobin was 8.2 g/dL, and hematocrit was 27%. Echocardiography showed cardiomegaly and a mild pericardial effusion. Chest radiography showed a mild right pleural effusion. Electrocardiography showed nonspecific ST-segment and T-wave changes in lead II and V2 to V5. A diagnosis of acute effusive pericarditis and right pleurisy was made. During hospitalization, she was kept in bed and received nasal oxygen, intravenous coemzyme A, adenosine triphosphate, vitamin C, antibiotics, and antiviral medicines. She recovered after this conservative management, and was discharged after 10 days.
After an uneventful 6 months, a small swelling with tenderness developed on the right side of the patient's chest near the right edge of the sternum in the fourth intercostal space. The lump developed very quickly within a week and began to beat at the same rate as the heart. She returned to our hospital. On physical examination, her heart rate was 96 beats per minute and blood pressure 96/60 mm Hg. A scar was found on the right lateral neck, just over the external jugular vein (Fig 1). The lump was conical, 1.5 cm in diameter, 1.2 cm high, and located near the right edge of the sternum in the fourth intercostal space. However, the volume and location of the pulsatile mass changed slightly with the heartbeat. A mild heart murmur was heard near the xiphoid. Two-dimensional echocardiography showed only mild tricuspid insufficiency. Chest radiography revealed a foreign body located in the right heart and the right anterior thorax. Nothing special was found by electrocardiogram. Chest computed tomography identified a high-density, sliver-shaped foreign body in the heart (Fig 2).
The patient was operated on through the sternotomy during cardiopulmonary bypass. After pericardiotomy, generalized adhesions were found, especially around the foreign body, which entered the right ventricle. The foreign body penetrated the right anterior surface of the right ventricle and entered the right thoracic cavity. A small skin incision was made just over the foreign body in the right chest, and a piece of glass was extracted under direct vision. The dagger-shaped glass shard was 4.5 cm long and 0.5 cm wide (Fig 3). The right ventricular wound was repaired with a running 4-0 polypropylene suture. There was no thrill palpable over the heart postoperatively. The pericardium was left open. A drainage tube was placed in the pericardial space and also in the right thoracic cavity. The patient's postoperative course was uneventful. Postoperative two-dimensional echocardiogram revealed mild tricuspid regurgitation, and no intracardiac shunt. The patient was discharged on postoperative day 7 in very good condition.
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Comment
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The patient's injury was strange. A large piece of glass had entered her heart from a peripheral vein after an accidental neck injury. Although the heart and right thorax were penetrated on the second day after the accident, the glass remained in the patient's heart for another half year. The glass nearly extracted itself from the heart.
In reviewing the literature, we found nearly all posttraumatic foreign bodies in the heart are metal objects, and no glass has been previously reported. The diagnosis is easily made for a metal foreign body by conventional radiology and echocardiography [1]. But glass is nonmetal, and not so easily discovered by conventional radiology. The patient had chest radiographs and two-dimensional echocardiography several times during the half-year interval, and no foreign body was found in any examination. The piece of glass was embedded in myocardium and surrounded by blood, pericardial fluid, and pleural effusion on chest radiographs, and could only be seen when the glass entered the thorax and after the surrounding liquids had been absorbed completely. To test the ability of echocardiography to detect glass, we put a piece of glass into a pig liver, and demonstrated that echocardiography could detect glass. The signal intensity was similar to a rib. From this experience, we speculate that computed tomography or magnetic resonance imaging may be more accurate for the diagnosis of nonmetal foreign bodies in the heart.
It was a miracle that the patient survived the glass wound to her right ventricle and initially recovered after 10 days of conservative management. We deduce that two factors helped the patient. First, the right ventricle was a low-pressure chamber. Second, the glass penetrated the heart, pericardium, and the right pleura at the same time, and intrapericardial fluid drained into the right pleural cavity in time to prevent severe acute cardiac tamponade.
Admitting our limited experience in treating chronic cardiac foreign bodies, we chose to remove the glass by a skin incision and repair the right ventricular wound through sternotomy during cardiopulmonary bypass. We found firm pericardial adhesions that allowed direct removal of the glass shard through a separate skin incision without producing acute pericardial temponade.
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Acknowledgments
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The authors thank Dr Weiguo Ma for reviewing the manuscript.
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References
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- Actis Dato GM, Arslanian A, Marzio PD, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heartreport of fourteen cases and review of the literature. J Thorac Cardiovasc Surg 2003;126:408-414.[Abstract/Free Full Text]
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J. Harrer, T. Holubec, and M. Brtko
A foreign body in the heart due to an unusual injury.
Ann. Thorac. Surg.,
September 1, 2009;
88(3):
985 - 987.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
