Ann Thorac Surg 2009;88:985-987. doi:10.1016/j.athoracsur.2009.01.059
© 2009 The Society of Thoracic Surgeons
Case Reports
A Foreign Body in the Heart Due to an Unusual Injury
Jan Harrer, MD, PhD,
Tomas Holubec, MD*,
Miroslav Brtko, MD, PhD
Department of Cardiac Surgery, Charles University Prague, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic
Accepted for publication January 22, 2009.
* Address correspondence to Dr Holubec, Department of Cardiac Surgery, Charles University Hospital, Sokolska 581, Hradec Kralove, 500 05, Czech Republic (Email: tomasholubec{at}email.cz).
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Abstract
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Penetrating heart injuries are immediate life-threatening situations. We present a case report of a 44-year-old man with a foreign body in his right heart. The injury happened while the man was working with a circular saw 15 months prior to the actual diagnosis. With respect to the size of the foreign body, its close proximity to the right coronary artery, the potential risk of bleeding, embolization, endocarditis or pericarditis, surgical therapy was indicated in spite of the fact that the patient was asymptomatic. The foreign body (a spring-segment of a roller blind) was successfully removed.
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Introduction
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Open or penetrating heart injuries are immediate life-threatening situations with a relatively high mortality rate. In most cases they are caused by war or gun-shot injuries [1]. Curious cases are those in which an entire foreign body remains lodged in the heart [2]. It is rare when such injuries result in neither cardiac tamponade nor acute heart symptoms, and it is likewise rare to have a substantial interval between such injuries and their actual diagnosis [2–4].
A 44-year-old man was cutting a roller blind with a circular saw. Suddenly he felt right-sided chest pain caused by a 3-cm long, lacerated wound in the fourth intercostal space in the medioclavicular line. The wound was sutured and dressed in the emergency room of a small hospital, and the patient was then discharged symptom-free. Fifteen months later he slipped on some ice and suffered a blunt chest trauma. A chest roentgenogram showed a spring-segment of the roller blind within the heart shadow.
A transthoracic echocardiography localized this body in the right atrium close to the tricuspid valve (Fig 1). Synkinetic movement of the peripheral third of the right coronary artery was recognized during cardiac catheterization. Therefore, we suspected the foreign body to lie in close proximity to this artery (Fig 2).
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Fig 1. Transthoracic echocardiogram (a modified four-chamber view) showing the spring segment (white arrow) within the right atrium close to the tricuspid valve.
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Fig 2. Right coronary angiography demonstrating close position of the spring segment (white arrow) to the right coronary artery.
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Because of the size of the body and its positional relationship to the anatomical structures of the heart, surgical treatment was indicated. A median sternotomy approach was used. Surprisingly, after opening the pericardial cavity, no adhesions or pathologic effusion were found. In the area of the atrioventricular groove, an infiltration was palpable near the right coronary artery, thus making direct removal of the foreign body too risky. A standard cardiopulmonary bypass was used. The heart was stopped with routine use of an aortic cross clamp and cold blood cardioplegia was administered into the aortic root. The right atrium was opened and a corroded wire (spring-segment) 65-mm long and 2-mm wide was seen. One end of the wire was in the right atrial wall. At the site of penetration through the endocardium there was an infiltration (granuloma), with signs of a rusty tint on the endocardium (metallosis). The spring segment was partly endothelized. The other end of the spring passed between the posterior and septal cusp of the tricuspid valve into the right ventricle, where it lay situated in the septum (Fig 3). By gently pushing and pulling at the place of insertion into the tissue, both ends of the wire were loosened and finally removed. The granulomatous tissue was excised. The right atrium was then sutured and the aortic clamp was released. The aorta clamp time was 16 minutes. The cardiopulmonary bypass lasted 33 minutes. The postoperative course was complicated by early postoperative bleeding from the periostal arterioli, which was the reason for re-exploration. An inflammatory reaction in the distal part of the sternotomy wound was the reason for the prolonged hospital stay. On postoperative day 23, the patient was discharged in good clinical condition.
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Fig 3. Intraoperative view demonstrating the half-liberated foreign body (the spring segment of a roller blind) in the right atrium. Black arrow indicates site of foreign body penetration through the right atrial wall with granulomatous tissue and signs of metallosis. The second end of the spring segment is passing between the posterior and septal cusp of the tricuspid valve into the right ventricle (white arrow).
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Comment
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It is extremely rare to suffer an open injury to the heart and experience no severe symptoms.
The injury previously discussed could be explained as follows: by absorbing kinetic energy (given off by the surface speed of the circular saw), the spring segment acts as a projectile. It is likely that the wire penetrated the right atrial wall longitudinally through the small puncture hole. Because of the elasticity of the right atrial wall, there was no bleeding into the pericardial cavity and thus no tamponade.
It is very interesting that no intrapericardial adhesions were found, which would indicate no serious primary injury. Another explanation for the asymptomatic posttraumatic course is that the hemopericardium (due to the foreign body penetrating the heart, pericardium, and right pleura) was drained into the right pleural cavity, which prevented acute cardiac tamponade. A process such as this was described by Yang and Shen [5]. Dato and colleagues [3, 4] described a similar case of a patient with a fragment of a circular saw embedded in the right ventricle.
Zhang and colleagues [2] reported a patient with a post-traumatic metallic foreign body partially retained in the posterior papillary muscle of the left ventricle.
Seipelt and colleagues [6] published a case report of coronary artery disease with two intracardially retained projectiles close to the right coronary artery and the left anterior descending artery diagnosed 44 years after the injury.
The dilemma of surgically removing intracardial foreign objects is delicate and has already been discussed in the literature many times [3, 4, 7].
Indication for surgical therapy is based on assessing the risk caused by the foreign body compared with the risk of surgical intervention itself.
Some possible complications of a foreign body lodged in the heart include: thrombosis with further embolization; bleeding from eroded vessels or from the wall of the heart chamber due to injuries caused by the sharp tips of the body; the anatomical proximity of the foreign body to the coronary vessel that might present the potential risk of reactive inflammatory changes in the arterial wall; endocarditis at the site of contact with the rusty surface of the foreign body; and heart rhythm disturbances.
Given the possibility of long-term complications if left untreated, we believe that surgical removal of the foreign body was preferable, despite the risk involved.
It is generally accepted that small, smooth, asymptomatic, noncontaminated foreign bodies embedded deep in the myocardium are not indicated for surgical removal [3, 4]. This recommendation can not be fully applied to objects in the left heart, where the risk of critical embolization is high [7].
Major foreign bodies in the heart area need to be removed. These are mostly iatrogenic migrating intravascular objects (ie, needles, catheters or their parts, and so forth) [7]. Such objects can generally be captured with special catheterization instruments (ie, lasso or baskets) drawn into the femoral vessel and then pulled out or surgically removed. Osteosynthetic material (Kirschner wires) migrating a short or even a long distance to the heart has also been described in the literature [8].
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References
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- Symbas PN, Vlasin-Hale SE, Picone AL, Hatcher CR. Missiles in the heart Ann Thorac Surgery 1989;48:192-194.[Abstract/Free Full Text]
- Zhang C, Hu J, Ni Y, Xu H. Successful salvage of post-traumatic metallic foreign body partially retained in the posterior papillary muscle of the left ventricle Interact Cardio Vasc Thorac Surg 2006;5:507-508.
- Dato Actis GM, Arslanian A, Di Marzio P, Filosso PL, Ruffini E. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature J Thorac Cardiovasc Surg 2003;126:408-414.[Abstract/Free Full Text]
- Dato Actis GM, Aidala E, Zattera GF. Foreign bodies in the heart: surgical or medical therapy? Ann Thorac Surg 1999;68:291-292.[Free Full Text]
- Yang X, Shen XA. Piece of glass in the heart Ann Thorac Surg 2006;81:335-336.[Abstract/Free Full Text]
- Seipelt RG, Vazquez-Jimenez JF, Messmer BJ. Missiles in the heart causing coronary artery disease 44 years after injury Ann Thorac Surg 2000;70:979-980.[Abstract/Free Full Text]
- 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]
- Durpekt R, Vojacek J, Lischke R, Burkert J, Spatenka J. Kirschner wire migration from the right sternoclavicular joint to the heart: a case report Heart Surg Forum 2006;9:840-842.
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Abstract
Introduction
