Asian Cardiovasc Thorac Ann 2006;14:63-65
© 2006 Asia Publishing EXchange Ltd
Sewing Needle in the Heart
Sachin Talwar, MCh,
K Ganapathy Subramaniam, MS,
Anandaraja Subramanian, DM,
Shyam S Kothari, DM,
A Sampath Kumar, MCh
Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India
For reprint information contact: A Sampath Kumar, MD Tel: 91 11 2658 8500 ext 3505 Fax: 91 11 2658 8663 Email: asampath_kumar{at}hotmail.com, Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.
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ABSTRACT
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An unusual case of a sewing needle in the heart is reported for its rarity. The relevant literature is briefly reviewed.
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INTRODUCTION
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Penetrating foreign bodies in the heart are a rare but serious form of cardiac injury. The objects usually comprise of bullets, acupuncture needles, fragments of Kirschner wires or even more rarely sewing needles. Only 15 cases of needles in the heart have been reported in the English medical literature in the last 25 years.1–5 We report a patient with a sewing needle fixed in the heart which was accurately diagnosed and successfully removed.
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CASE REPORT
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A 4-year-old male child was brought to the emergency department with a history of accidental injury with a sewing needle in the chest while a button was being stitched to his shirt. The child had sustained a needle prick 36 hours earlier and when he winced in pain and moved reflexly, the mother lost control over the needle, which was driven into his chest. On examination, his vital signs were stable. There was a mark of a needle prick in the right parasternal region in the 5th intercostal space. Apical impulse was normally palpable and cardiac percussion was within normal limits. Heart sounds were normal.
Chest radiograph (postero-anterior view) revealed a needle within the cardiac silhouette (Figure 1
). On a lateral chest radiograph, a similar finding was noted and the object was seen to overlie the shadow of the right ventricle. A chest CT scan showed the needle lying across the right and left ventricles (Figure 2). Two-dimensional echocardiography was performed and revealed the needle extending from the right ventricle below the tricuspid valve passing through the interventricular septum and going into the left ventricle (Figure 3). One end of the needle was seen embedded into the lateral wall of the left ventricle and the other end was not clearly defined. There was no thrombus, valve regurgitation or pericardial effusion.
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Figure 1. Chest radiograph (postero-anterior view) showing a needle (Arrow) within the cardiac silhouette.
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Figure 3. Echocardiogram (apical four-chamber view) showing the needle (Arrow) extending from the right ventricle (RV) and passing through the interventricular septum into the left ventricle (LV).
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The patient was taken to the cardiac catheterization laboratory and percutaneous removal was attempted under fluoroscopic guidance in the hope of avoiding surgery. However, this was unsuccessful and the patient was taken up for surgery. Transesophageal echocardiography (TEE) was carried out after endotracheal intubation to aid in accurate localization of the needle. A limited anterior thoracotomy was performed through the left 4th intercostal space and the pericardium was opened anterior to the left phrenic nerve. There was minimal blood-stained pericardial effusion and the needle ends could not be seen or felt. With the left index finger, the needle was palpated through the right atrial wall. It was gently pushed out without incising the muscle, grasped with a small artery forceps, and pulled out of the lateral wall of the left ventricle. The needle was 4 cm long and 1 mm thick, complete with the sharp end and the eye (Figure 4). TEE showed no other abnormality. Post-operative recovery was uneventful.
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DISCUSSION
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Cardiac injuries with sharp pointed objects are not uncommon. In 1969, Schechter and Gilbert6 reviewed 157 published reports of injuries to the heart and great vessels from pins and needles. Most of these were accidental or self-inflicted due to an underlying psychiatric illness. They have also been reported following angiographic procedures, intravenous injections, and puncture with acupuncture needles. In 1998, Jamilla and Casey1 reviewed the 10 published cases of sewing needles infixed in the heart and pericardium and reported another case. Subsequently, four more cases have been reported in the English medical literature.2–5 Only three of these patients were 12 years of age or less. The youngest was a 6-week-old baby, the other two were 2 and 12 years of age.
In the 15 cases reported in the last 25 years (Table 1), 11 were the result of self-inflicted injuries (patients 1, 3 and 5 – 13), the rest were accidental injuries (patients 2, 4 and 14). Patients with these foreign bodies in the heart usually presented with dyspnea due to an enlarging pericardial effusion, valve dysfunction or associated pneumothorax. Partly embedded needles caused maximal trauma due to the motion of the needle with each cardiac contraction. Three of these had cardiac tamponade, two had mural thrombus formation, and one each had valve dysfunction, recurrent arterial embolism, chronic constrictive pericarditis, and pneumothorax. The rest of the patients were asymptomatic.
Determination of the exact location of the needle body is important to ensure complete removal. This can usually be accomplished by a combination of CT scan of the chest, two-dimensional echocardiography, and fluoroscopy. Intraoperative fluoroscopy and TEE facilitate exact localization and removal.
Untreated, patients may be asymptomatic. However, because of their sharp nature, needles can rapidly migrate through the tissues,5 which can result in cardiac tamponade from hemopericardium, hemothorax, and pneumothorax. In the absence of migration, mural thrombi may form, leading to repeated embolization. Rarely, there may be valvular regurgitation, especially with needles embedded in the ventricular septum. In long standing cases, infective endocarditis may develop. Early diagnosis and prompt removal are the treatment of choice.
In all but one of the reported cases, the needles were removed surgically. In one patient, no intervention was carried out.1 Six patients required extracorporeal circulation for successful surgical extraction. Percutaneous removal of intracardiac catheter fragments and guidewires was first reported 30 years ago.7 Since then a large number of techniques have been used for this purpose, including the use of loop snares, hook-shaped catheters, basket catheters, pig-tail catheters, and endomyocardial biopsy catheters.7 These catheters are usually passed via the femoral artery or via the femoral vein or jugular vein. In a novel approach, an intracardiac catheter fragment was removed in a neonate by passing a catheter through the umbilical vein.8 However, percutaneous removal of intracardiac needles has not been reported previously.
Our case is unique in that no end of the needle was visible or felt on the surface of the heart. However, because the needle was long and impacted in the myocardium, it was possible for us to remove it without cardiopulmonary bypass after accurate localization using TEE.
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REFERENCES
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- Jamilla FP, Casey LC. Self-inflicted intramyocardial injury with a sewing needle: a rare cause of pneumothorax. Chest 1998;113:531–4.[Abstract/Free Full Text]
- Gallerani M, Ferrari F, Magenta G, Barboso G, Antonelli AM, Manfredini R. A needle infixed in the heart. Am J Emerg Med 1998;16:662–3.[Medline]
- Mihmanli I, Kurugoglu S, Kantarci F, Atakir K, Akman C. Intracardiac needle in a 12-year-old girl with self-injurious behaviour. Pediatr Radiol 2002;32:209–10.[Medline]
- Sayin AG, Besirli K, Arslan C, Canturk E. A case of intramyocardial sewing needle extracted without stopping the heart. Injury 2002;33:276–7.[Medline]
- Inoue T, Iemura J, Saga T. Delayed cardiac tamponade caused by self-inserted needles. Can J Cardiol 2003;19:306–8.[Medline]
- Schechter DC, Gilbert L. Injuries of the heart and great vessels due to pins and needles. Thorax 1969;24:246–53.[Abstract/Free Full Text]
- Cheng TO. Use of myocardial biopsy catheter in retrieving "lost" intracardiac device. Tex Heart Inst J 2003;30:165.[Medline]
- Perez-Martinez A, Bento-Bravo L, Martinez-Bermejo MA, Conde-Cortes J, Lezaun R, Egues J. Fracture and intracardiac migration of a neonatal venous catheter-extraction via the umbilical pathway. Pediatr Radiol 2002;32:211.[Medline]
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ABSTRACT
INTRODUCTION
