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Ann Thorac Surg 2006;81:1895-1897
© 2006 The Society of Thoracic Surgeons

Case report

Chronic Heart Perforation With 13.5 cm Long Kirschner Wire Without Pericardial Tamponade: An Unusual Sequelae After Shoulder Fracture

Igor Medved, MD a , * , Ognjen Simic, MD, PhD a , Marina Bralic, MD c , Valter Stemberga, MD d , Miljenko Kovacevic, MD a , Ante Matana, MD, PhD b , Alan Bosnar, MD, PhD d

a Department of Cardiac Surgery, University Hospital Rijeka, Rijeka, Croatia
b Department of Cardiology, University Hospital Rijeka, Rijeka, Croatia
c Department of Histology and Embryology, Faculty of Medicine, University of Rijeka, Rijeka, Croatia
d Department of Forensic Medicine, Faculty of Medicine, University of Rijeka, Rijeka, Croatia

Accepted for publication June 20, 2005.

* Address correspondence to Dr Medved, Department of Cardiac Surgery, University Hospital Rijeka, T. Strizica 3, 51 000 Rijeka, Croatia (Email: igor.medved{at}ri.t-com.hr).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
We report a unique case of cardiac embolization with the Kirschner wire that has been used for osteosynthesis for 24 months previously. According to the complete analysis of medical records and autopsy report, the wire had migrated from the right humeroscapular joint to the heart. Although migration of a Kirschner wire has been reported in the literature, migration of the wire with a total length of 13.5 cm with no pericardial tamponade, despite myocardial perforation, has not been previously described.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Migration of orthopedic wires to solid organs or body cavities has been reported in the literature. This case report documents migration of a Kirschner wire used in the shoulder fixation.

A 67-year-old woman with a history of alcohol abuse was found in the park unconscious and subfrozen, and she was subsequently admitted to our hospital. On admission, laboratory data showed severe thrombocytopenia (platelet count, 6,000), anuria, and renal and hepatic failure. The electrocardiogram demonstrated sinus rhythm (120/min) with no changes in ventricular complex or segment elevations. Routine upright anterior-posterior chest roentgenogram revealed a metallic foreign body over the cardiac silhouette. Her medical history was significant for fracture of a right humerus with placement of Kirschner wires 24 months previously (Figs 1A, 1B). Computed tomography and transthoracal echocardiography confirmed the presence of a metal wire situated in the heart (Figs 2A, 2B). The echocardiogram showed a 50% ejection function.


Figure 1
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  		Fig 1. (A) Postoperative roentgenogram after osteosynthesis of the right humerus with the Kirschner wires (see arrow). (B) Chest roentgenogram revealing a metallic foreign body in the thorax. (Arrow indicates the wire).

 

Figure 2
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  		Fig 2. (A) Computed tomographic scan showing the wire (see arrow) in the heart. (B) Subcostal two-dimensional echocardiographic image shows the wire (see arrow) tip that appears to cross the right ventricular wall. (AO = aorta; LA = left atrium; RA = right atrium; RV = right ventricle.)

 
The patient died from multiorgan failure due to her disease 36 hours post-admission. Autopsy was performed the next day revealing the Kirschner wire in right ventricle, which was entrapped in the posterior papillary muscle near the tricuspid valve. The total length of the Kirschner wire was 13.5 cm. Approximately an 11 cm long segment of the wire was situated in the cavity of right ventricle with 0.5 cm of its length pricked in the myocardium of the right ventricle; whereas approximately 2 cm of its length was found penetrating the pericardium, which ended in the left pleural space (Figs 3A, 3B). A small amount of serous exudation that was not tinged with blood was observed as well.


Figure 3
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  		Fig 3. (A, B) Autopsy report demonstrates the wire in the cavity of the right atrium, which is embedded in the papillary muscle of the right ventricle, perforating myocardium, and pericardium, ending in the left pleural space.

 
The microscopic examination of the heart showed epicardium covered with fibrin deposits, whereas the endocardial surface was covered with a thick layer of granulation tissue. In addition, chronic inflammatory infiltration consisting of macrophages and lymphocytes was observed on pericard (Figs 4A, 4B).


Figure 4
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  		Fig 4. The microscopical appearance of the heart. (A) Inflammatory infiltration observed in pericardial layer. (B) Epicardium covered with fibrin deposits. (Hematoxylin and eosin; magnification x20.)

 

   Comment
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We presume that the wire migration in our patient occurred as a result of shoulder trauma from the patient's habitual abuse of alcohol. Although mechanisms that include respiratory excursion or gravitational forces may be proposed, most likely the wire embolized the heart from a peripheral vein and ultimately lodged in the right ventricle [1–4].

Thus this case underlines inconsistency between the length of the wire and the period of time it was settled in the heart. To date almost all patients presented with acute symptoms [4]. In our case the wire did not produce particular symptoms and the diagnosis was made after a routine examination [4]. The time of the wire embolization to the heart is uncertain, but according to inflammatory reaction the wire was embedded in the heart for approximately 1 year prior to diagnosis.

Interestingly, no tamponade occurred in our patient. We hypothesize the main reason for this was that the length of the Kirschner wire, protruding the heart transversally through the papillary muscle it had blocked any leakage of the blood into the pericardial cavity.

This case reminds us that serious precautions should be taken if orthopedic wires are to be used for fixation of fractures and dislocations. Moreover, wires have to be bent over in order to prevent their migration.


   References
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 Abstract
 Introduction
 Comment
 References
 

  1. Anic D, Brida V, Jelic I, Orlic D. The cardiac migration of a Kirschner wirea case report. Tex Heart Inst J 1997;24:359-361.[Medline]
  2. Goodsett JR, Pahl AC, Glaspy JN, Schapira MM. Kirschner wire embolization to the heartan unusual cause of pericardial tamponade. Chest 1999;115:291-293.[Abstract/Free Full Text]
  3. Le Maire SA, Wall MJ, Mattox KL. Needle embolus causing cardiac puncture and chronic constrictive pericarditis Ann Thorac Surg 1998;65:1786-1787.[Abstract/Free Full Text]
  4. Actis Dato GM, Arslanian A, Di Marzio P, 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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