CASE REPORT – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 19 (2014) 881–882 doi:10.1093/icvts/ivu272 Advance Access publication 16 August 2014
Metal splinter ejected by circular saw into the left ventricle Petr Santavy*, Martin Troubil and Vladimir Lonsky Department of Cardiac Surgery, Palacky University Teaching Hospital, Olomouc, Czech Republic * Corresponding author. Department of Cardiac Surgery, Palacky University teaching hospital, I.P. Pavlova 6, 77900 Olomouc, Czech Republic. Tel: +420-58-8442344; fax: +420-58-8442377; e-mail: [email protected] (P. Santavy). Received 1 June 2014; received in revised form 19 July 2014; accepted 22 July 2014
Abstract We report a case of a metal splinter ejected by a circular saw tooth from a wooden board into the left ventricle of the heart. A 35-year old man was admitted second day after accident attributed to work complaining about general weakness. Only a small non-bleeding wound was found near his sternum. CT scan showed a metal wire entrapped inside his heart. Successful removal was done during surgery.
INTRODUCTION
DISCUSSION
Foreign bodies in the heart are often caused by traumatic and iatrogenic reasons and may be retained in different locations of the heart. Objects ejected by a circular saw might acquire very high velocity and act as a projectile. We report an metal splinter ejected into the left ventricular cavity and its successful removal.
Retention of a foreign body in the heart or great vessels can be the result of a direct penetrating injury or embolism. The clinical manifestation can vary from an asymptomatic state to haemodynamic instability. A high-velocity small object can leave almost no skin injury and can receive various mediastinal trajectories. History and chest X-ray is usually sufficient for the evidence of a metal foreign object. More precise localization is usually provided by multislice CT. Echocardiography may be very helpful for guidance in the diagnosis, characterization and extraction of intracardiac foreign bodies [1]. The presence of symptoms and risk of embolism are primary indications for surgery, especially in cases of cardiac effusion or tamponade. Only in asymptomatic patients, where the foreign body is incidentally diagnosed a long time after trauma and is completely embedded in the myocardium or in the pericardial space, could it be possibly left in place [2, 3]. A median sternotomy approach is usually used for extraction. Cardiopulmonary bypass may not be necessary only in cases where part of the foreign body is clearly visible and can be easily removed. Commonly, during surgery, location of the foreign body is difficult. Exact localization is necessary in these cases to avoid unnecessary and inappropriate incisions [2]. The use of intraoperative transoesophageal echocardiography can be useful to differentiate between an intramuscular or intracavitary position. Perioperative mobile X-ray is usually necessary for localization of small metal objects. In our case, a high-velocity metal splinter entered the chest cavity obliquely right next to the sternum, and then entered the pericardium, went through the pulmonary artery and the right ventricle into the left ventricle. To the best of our knowledge, this is the second published case of a high-velocity metal object ejected by a circular saw into the heart [4].
CASE REPORT A 35-year old man was admitted to regional hospital the second day after a work accident, complaining of general weakness. He was cutting a wooden board using a circular saw and had suddenly felt a sharp pain next to his sternal bone, where a small nonbleeding puncture wound was located (Fig. 1A). On regular chest X-ray scan, a contrast image of a foreign body inside the heart was observed. CT scan confirmed a metal object inside the left ventricle and mild pericardial effusion (Fig. 2A and B). He was then transferred to our clinic, where surgical removal was indicated. Transthoracic echocardiography showed a highly echogenic, moving linear object inside the left ventricular cavity and pericardial effusion (Fig. 1B). After median sternotomy, the pericardial sac was opened and 300 ml dark blood was evacuated. The already formed non-bleeding puncture site in the pulmonary artery was visible. The ascending aorta and both venae cavae were cannulated for cardiopulmonary bypass. A mobile C-arm X-ray machine was brought to the theatre and a floating metal foreign body inside the left ventricle was confirmed (Fig. 2C). Aortic cross-clamping was done and cardioplegia was introduced. During search attempts under continuous X-ray imaging, this small metal splinter was accidentally ‘shaken out’ across the mitral valve into the left atrium and the left lower pulmonary vein, from where it was retrieved (Fig. 1C). The patient made an uneventful recovery and was discharged from hospital 6 days postoperatively.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Foreign body • Left ventricle • Intracardiac migration • Metal splinter
882
P. Santavy et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A) Chest entering site, (B) echo image, (C) removed metal splinter (3 cm long).
Figure 2: (A and B) CT scan with metal object inside the left ventricle, (C) perioperative mobile X-ray image.
Conflict of interest: none declared.
REFERENCES [1] Fry SJ, Picard MH, Tseng JF, Briggs SM, Isselbacher EM. The echocardiographic diagnosis, characterization and extraction guidance of cardiac foreign bodies. J Am Soc Echocardiogr 2000;13:232–9.
[2] Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles: a review of the literature and personal experience. Ann Surg 1990;211: 639–47. [3] Actis Dato GM. Foreign body in the heart: surgical or medical therapy? Ann Thorac Surg 1999;68:291–7. [4] Actis Dato GM, Arslanian A, DiMarzio 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; 126:408–14.
Interactive CardioVascular and Thoracic Surgery 19 (2014) 881–882 doi:10.1093/icvts/ivu272 Advance Access publication 16 August 2014
Metal splinter ejected by circular saw into the left ventricle Petr Santavy*, Martin Troubil and Vladimir Lonsky Department of Cardiac Surgery, Palacky University Teaching Hospital, Olomouc, Czech Republic * Corresponding author. Department of Cardiac Surgery, Palacky University teaching hospital, I.P. Pavlova 6, 77900 Olomouc, Czech Republic. Tel: +420-58-8442344; fax: +420-58-8442377; e-mail: [email protected] (P. Santavy). Received 1 June 2014; received in revised form 19 July 2014; accepted 22 July 2014
Abstract We report a case of a metal splinter ejected by a circular saw tooth from a wooden board into the left ventricle of the heart. A 35-year old man was admitted second day after accident attributed to work complaining about general weakness. Only a small non-bleeding wound was found near his sternum. CT scan showed a metal wire entrapped inside his heart. Successful removal was done during surgery.
INTRODUCTION
DISCUSSION
Foreign bodies in the heart are often caused by traumatic and iatrogenic reasons and may be retained in different locations of the heart. Objects ejected by a circular saw might acquire very high velocity and act as a projectile. We report an metal splinter ejected into the left ventricular cavity and its successful removal.
Retention of a foreign body in the heart or great vessels can be the result of a direct penetrating injury or embolism. The clinical manifestation can vary from an asymptomatic state to haemodynamic instability. A high-velocity small object can leave almost no skin injury and can receive various mediastinal trajectories. History and chest X-ray is usually sufficient for the evidence of a metal foreign object. More precise localization is usually provided by multislice CT. Echocardiography may be very helpful for guidance in the diagnosis, characterization and extraction of intracardiac foreign bodies [1]. The presence of symptoms and risk of embolism are primary indications for surgery, especially in cases of cardiac effusion or tamponade. Only in asymptomatic patients, where the foreign body is incidentally diagnosed a long time after trauma and is completely embedded in the myocardium or in the pericardial space, could it be possibly left in place [2, 3]. A median sternotomy approach is usually used for extraction. Cardiopulmonary bypass may not be necessary only in cases where part of the foreign body is clearly visible and can be easily removed. Commonly, during surgery, location of the foreign body is difficult. Exact localization is necessary in these cases to avoid unnecessary and inappropriate incisions [2]. The use of intraoperative transoesophageal echocardiography can be useful to differentiate between an intramuscular or intracavitary position. Perioperative mobile X-ray is usually necessary for localization of small metal objects. In our case, a high-velocity metal splinter entered the chest cavity obliquely right next to the sternum, and then entered the pericardium, went through the pulmonary artery and the right ventricle into the left ventricle. To the best of our knowledge, this is the second published case of a high-velocity metal object ejected by a circular saw into the heart [4].
CASE REPORT A 35-year old man was admitted to regional hospital the second day after a work accident, complaining of general weakness. He was cutting a wooden board using a circular saw and had suddenly felt a sharp pain next to his sternal bone, where a small nonbleeding puncture wound was located (Fig. 1A). On regular chest X-ray scan, a contrast image of a foreign body inside the heart was observed. CT scan confirmed a metal object inside the left ventricle and mild pericardial effusion (Fig. 2A and B). He was then transferred to our clinic, where surgical removal was indicated. Transthoracic echocardiography showed a highly echogenic, moving linear object inside the left ventricular cavity and pericardial effusion (Fig. 1B). After median sternotomy, the pericardial sac was opened and 300 ml dark blood was evacuated. The already formed non-bleeding puncture site in the pulmonary artery was visible. The ascending aorta and both venae cavae were cannulated for cardiopulmonary bypass. A mobile C-arm X-ray machine was brought to the theatre and a floating metal foreign body inside the left ventricle was confirmed (Fig. 2C). Aortic cross-clamping was done and cardioplegia was introduced. During search attempts under continuous X-ray imaging, this small metal splinter was accidentally ‘shaken out’ across the mitral valve into the left atrium and the left lower pulmonary vein, from where it was retrieved (Fig. 1C). The patient made an uneventful recovery and was discharged from hospital 6 days postoperatively.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Foreign body • Left ventricle • Intracardiac migration • Metal splinter
882
P. Santavy et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A) Chest entering site, (B) echo image, (C) removed metal splinter (3 cm long).
Figure 2: (A and B) CT scan with metal object inside the left ventricle, (C) perioperative mobile X-ray image.
Conflict of interest: none declared.
REFERENCES [1] Fry SJ, Picard MH, Tseng JF, Briggs SM, Isselbacher EM. The echocardiographic diagnosis, characterization and extraction guidance of cardiac foreign bodies. J Am Soc Echocardiogr 2000;13:232–9.
[2] Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles: a review of the literature and personal experience. Ann Surg 1990;211: 639–47. [3] Actis Dato GM. Foreign body in the heart: surgical or medical therapy? Ann Thorac Surg 1999;68:291–7. [4] Actis Dato GM, Arslanian A, DiMarzio 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; 126:408–14.
