Ann Thorac Surg 2004;77:1102
© 2004 The Society of Thoracic Surgeons
Images in cardiothoracic surgery
Needle embolism to the heart
Craig J. Baker, MDa,
John J. Nigro, MDa,
Casey W. Daggett, MDa,
Winfield J. Wells, MDa*
a Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California, USA
* Address reprint requests to Dr Wells, Division of Cardiothoracic Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd, MS 66, Los Angeles, CA 90027, USA
e-mail: wwells{at}chla.usc.edu
A 15-year-old girl presented with palpitations and chest pains that radiated to the left shoulder. One ye prior, during a bout of depression, she had placed sewing needles into both antecubital fossa. Whereas the needle on the right side had been extracted, the one in her left arm was never found.
On physical examination there were normal vital signs including a regular heart rhythm. Breath sounds were clear and there was no pericardial rub or cardiac murmurs. Chest radiograph showed a metallic foreign body within the cardiac shadow (Fig 1A), which was situated anteriorly on the lateral projection (Fig 1B). Computer-assisted tomography (Fig 2) confirmed the presence of a foreign body (arrow) in the right ventricular wall just below the tricuspid valve. Transthoracic echocardiogram revealed that the foreign body moved synchronously with cardiac contractions. No significant pericardial effusion was evident.
An urgent operation was performed via a lower sternotomy incision. Bloody pericardial fluid was found and the diaphragm adjacent to the inferior wall of the right ventricle was abraded and inflamed. A punctate area with mild fibrotic reaction was seen on the inferior wall of the right ventricle but no foreign body could be seen or palpated with the heart contracting. The patient was placed on cardiopulmonary bypass and with the heart arrested a mass could be palpated within the right ventricular myocardium. The myocardium was incised and a 2-cm long sewing needle was removed. The patient made a rapid recovery and was discharged on postoperative day 2.
The management of foreign body emboli to the heart remains somewhat controversial and should be individualized. Although nonoperative management of asymptomatic blunt foreign body emboli has been advocated, this patient underwent an operation because of the type of embolus (needle) and symptoms suggestive of pericardial and diaphragmatic irritation in addition to palpitations. Management of embolic objects to the heart should be based on the potential for complications relative to the risks of the proposed procedure.
