Generally, foreign bodies may reach the heart via direct penetration due to local trauma or through intravenous migration after certain medical procedures, such as catheter pieces, pacemaker electrodes and stents 2,3. Darko et al. reported a case of Kirschner wire moving from right hip to right ventricle after an orthopedic surgery4. Foreign bodies with sharp nature have a tendency to migrate though tissues and lead to serious complications. Wang et al. reported a case that a swallowed fish bone resulting in cardiac injury and devastating tamponade5. In the present case, there was a risk that the needle might penetrate the diaphragm into the abdominal cavity, which would probably cause abdominal organ damage and bleeding. Once in the abdominal cavity, it would be more difficult to detect the fine needle surgically. Another, the needle might enter the right ventricle and injure the tricuspid valve, ventricular septum, or pulmonary artery, leading to valvular reflux, ventricular septal defect, infective endocarditis or thrombosis6. In addition, the increasing pericardial effusion might cause devastating tamponade. The clinicians should be alert that the foreign bodies with sharp nature could migrate though tissues fast with serious consequences. The dynamic monitoring of the foreign bodies’ location is urgently required.
According to our experience and cognition, a self-inflicted foreign body migrating from peripheral tissues to the heart was uncommon and rarely reported. Also, this is a rare report to record the dynamic movement of the foreign body in the myocardium perioperatively.
Preoperative localization of the foreign body was crucial for its surgical removal. X-rays, CT scans, fluoroscopy, and echocardiography were commonly used to locate the foreign body in the heart7. Studies showed that TTE provides information regarding the size, and location of cardiac foreign bodies with almost 100% sensitivity8. Moreover, TEE is a favorable imaging modality in assessing functional and structural damage of the heart, especially in the unstable patient9. It was important to note that the foreign body may migrate with blood flow, gravity, or through the myocardial tissues along with the systolic and diastolic beat of heart, resulting in location changes. Up to now, most operative suites lack real-time CT or magnetic resonance imaging (MRI). Kumar et al. reported a case in which the preoperative radiological imaging showed a foreign body in the posterior mediastinum of a blast-injury victim7. However, the foreign body could not be located in the area identified preoperatively during the extended right posterolateral thoracotomy. Interestingly, the intra-operative TEE showed it in the left atrium, which later migrated into the left ventricle necessitating a change in surgical approach for its removal.
In the present case, it was infered that the speculated migrating path of the needle was as follows. The needle rested on the left neck for at least 6 months before it penetrated into the peripheral vein. Thus, the needle migrated, by both blood flow and gravity, to the superior vena cava, right atrium, and then settled in right ventricle tentatively. With the continuous beats of heart, the needle tip penetrated the anterolateral wall of the right ventricle, and injured the diaphragm nearby. Fortunately, the needle did not penetrate the diaphragm or detach from the heart. In this process, the pericardial effusion developed due to the injured small myocardial vessels. Then the needle moved back towards the right ventricle, the process of which was captured by echocardiography. In a few hours, the length of the needle in the pericardial cavity reduced from 2.5 cm to 0.5 cm, indicating that the migrating distance of the needle moving into the right ventricle was about 2.0 cm. An emergency surgery was immediately carried out and the needle was successfully removed without open heart surgery and cardiopulmonary bypass (CPB). If there had been any delay, it would be possible that the needle might enter the right ventricle and was not visible on the surface of the visceral pericardium. In that case, the patient would have to undergo open heart surgery. The dynamic monitoring of the needle’s location using echocardiography helped clinical decisions and benefited the patient.
In conclusion, echocardiography with a combination of both TTE and TEE has a unique advantage in providing real-time, continuous and accurate monitoring of cardiac foreign bodies to help determination of optimal surgical method without radiation hazards, which is worth popularizing in clinical practice.