© 2014, Wiley Periodicals, Inc. DOI: 10.1111/echo.12795

Echocardiography

REVIEW ARTICLE

Foreign Bodies in the Heart Marina Leitman, M.D., and Zvi Vered, M.D., F.A.C.C., F.E.S.C. Department of Cardiology, Assaf Harofeh Medical Center, Sackler School of Medicine, Tel Aviv University, Zerifin, Israel

Background: Foreign bodies in the heart are rare, may reach the heart by different ways, and cause serious complications. X-ray, computerized tomography, and echocardiography are main diagnostic modalities. Foreign body can be removed surgically, percutaneously or can be managed conservatively. In this work, we analyzed 100 published cases of a foreign body in the heart and 4 cases that were identified in our hospital. Methods: We searched the literature for foreign body in the heart and found 100 published previously cases. Additional 4 cases were identified in our echo laboratory. A total series of 104 patients with a foreign body in the heart were analyzed for the etiology, clinical presentation, symptoms, complications and management. Results: Mean patients’ age was 46, there were more men than woman 73 versus 31 [P < 0.00005]. The most common foreign bodies were parts of inferior vena cava filters and devices implanted for relieving hydrocephalus. Foreign bodies in the heart were symptomatic in 56% of patients. Right heart chambers were occupied more often. A total of 20% presented within the first 24 hours and 30% of patients presented years after the penetration of the foreign body. A majority of foreign bodies reached the heart by migration [88%]. Mortality was reported in 4 patients [3.8%]. Here 54% of the patients underwent surgical and 29% percutaneous removal of the foreign body, while 14% were followed conservatively. Conclusion: Foreign bodies in the heart may present with a wide variety of symptoms. Physicians should be aware of this rare and peculiar complications which may be fatal. Larger devices may result in more severe complications. (Echocardiography 2015;32:365–371) Key words: foreign body, heart, echocardiography A foreign body can be left in the heart or reach the heart after medical procedures or directly. For a long time, traditionally x-ray–based methods have been used for initial and definite diagnosis of foreign body in the heart. During the last years modern echocardiographic systems have allowed detailed cardiac examination, are often used as the sole modality or may be used in combination with chest x-ray or computerized tomography in diagnosis of foreign bodies in the heart. A spectrum of clinical scenarios, presentation, complications of a foreign body in the heart is being widely studied. In the last few years, endovascular removal of the foreign body from the heart was performed and was successful. We found in the literature 100 published cases of a foreign body in the heart and 4 cases were identified in our hospital. We analyzed 104 patients for demographic data, epidemiology, type of foreign body, presentations, complications treatment, and outcome. Methods: Literature data were searched for a foreign body in the heart and 100 such cases were found. We Address for correspondence and reprint requests: Marina Leitman, M.D., Department of Cardiology, Assaf Harofeh Medical Center, Zerifin 70300, Israel. Fax: +972 89778412; E-mail: [email protected]

analyzed digital database of our echo laboratory between 2008 and 2013 and searched for the presence of foreign bodies. Of 30,000 echocardiographic examinations, 4 studies with foreign bodies in the heart were identified. These studies were reviewed and detailed medical history and follow-up were recorded. All these 104 cases with a foreign body in the heart were analyzed regarding the cause, demographic data, causative procedure, clinical presentation, symptoms, complications, outcome, and treatment. Results: The results of 104 patients with foreign bodies in the heart are summarized in Tables I–IV. The mean age of the patients was 46 years (3 months–88 years), significantly more men than women 73 versus 31, P < 0.00005. The most common foreign bodies (Table I) were parts of the inferior vena cava filters and devices implanted for relieving hydrocephalus. The rarest finding was a nephrostomy catheter, inadvertently inserted into the renal vein which then migrated to the heart.49 Foreign bodies were associated with symptoms in 58 patients [56%] (Table II). In 2 patients symptoms were not reported. The most frequent symptoms were dyspnea and arrhythmias, 4

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TABLE I

TABLE III

Occurrence of Different Foreign Bodies in the Heart Inferior vena cava filter: struts, limbs, total1–12 Devices for treatment of hydrocephalus13–23 Ventriculo-atrial shunts VP shunts Pudenz-Holter valve Port-a-cath /TIVD (Totally implantable intravenous device)24–30 Stents: Wallstents, Palmatz stent, stent for Budd–Karri syndrome, stent for porto-systemic shunt in liver cirrhosis31–40 Different catheters and wires: retained wires, cannula, stylet, catheter postangiography; Swan–Ganz catheter fragments13,41–49 Acrylic cement embolism (percutaneous vertebroplasty)50–55 Brachytherapy radioactive seeds56 Pacemaker leads (usually external)57–60 Post sternal surgery: Ravitch surgery for pectus exacavatus, broken wire for sternal fixation post coronary bypass surgery61–63 Kirshner wire for fixation of pelvis, femur64,65 Work/home accidents: circular saw fragments, needles, staple, pieces of metall, needles for acupuncture, Tattoo42,66–74 Bullets/ shrapnel/ pellets, grenade fragment42,75–77

Timing Since Penetration of the Foreign Body to Presentation 14 4 8 2 9 11

20% 15% 12% 15% 7% 30%

TABLE IV Localization of Foreign Bodies in the Heart

6 3 5 3

2 12

9

Predominant Symptoms in Patients with Foreign Bodies in the Heart 58 5 3 5 4 16 5 5 3 3 7 8 13

Several symptoms: *in one patient VT was accompanied with syncope, †in another pericardial effusion infected with S. aureus, ‡in all 5 patients with cardiopulmonary arrest, ventricular arrhythmia was present and in 1 patient with rapid atrial flutter presenting symptom was CHF. 4 patients with CHF had dyspnea; 2 patients complained of dyspnea and chest pain.

patients suffered a cardiorespiratory arrest, 7 patients developed pericardial effusion with or without tamponade and 20% of the patients 366

21 16 12 16 7 31

In 1 patient accurate timing is not clear.

16

TABLE II

Symptomatic Wound Myocardial infarction Congestive heart failure Central nervous system symptoms Dyspnea Chest pain Cardiopulmonary arrest Syncope* Abdominal symptoms Tamponade/pericardial effusion† Infection Arrythmia‡

Up to 24 hours Up to 1st week Up to 1st month Up to 6 months Up to 1 year Years

RA RV LV LA Pericardium PA involvement

44 (42%) 77 (74%) 7 (7%) 3 (3%) 7 (7%) 19 (18%)

RA = right atrium, RV = right ventricle, LV = left ventricle, LA = left atrium, PA = pulmonary artery.

presented these symptoms during the first 24 hours while 30% presented symptoms after 1 year since the penetration of the foreign body (Table III). Right heart chambers were involved more often than the left (Table IV), while the right ventricle was the most frequent location of the foreign body [70%]. The pulmonary artery was involved in 13% of the patients. In the vast majority of cases, foreign bodies reached the heart through migration [88%]: catheters, pacemaker wires, fragments of inferior vena cava filters, Other reached directly [11%]— bullets, sternal struts or wires, staple, fragments of circular saw. In 2 cases, the foreign body remained in the heart after a medical procedure: fragment of a Swan-Ganz catheter was retained in the right side of the heart42 and a stylet in the interatrial septum13 after diagnostic catheterization. Chest x-ray, CT, angiography or fluoroscopy were the primary diagnostic modalities in 81 patients [78%], while echocardiography in 41 patients [39%]. Mortality was reported in 4 patients [3.8%]10,12,13,45: among these 54% of the patients underwent surgery, 29% underwent a percutaneous removal of the foreign body, and 14% were followed conservatively. Four patients with foreign bodies identified in our hospital are presented below: Case 101: A 61-year-old woman had undergone ventriculoatrial shunt due to hydrocephalus 39 years ago,

Foreign Body in the Heart

which was replaced twice with ventriculo-peritoneal shunts 18 and 12 years ago, respectively, presented with dyspnea during last few months that increased before admission. Oxygen saturation was 88–92%, pulse rate 106 per minute, and blood pressure 109/ 76 mmHg. Electrocardiogram showed sinus tachycardia with prominent P waves. CT angiography excluded pulmonary embolism, but detected a foreign body—a catheter in the right ventricle protruding into the main and the left pulmonary artery. Echocardiography revealed a distal catheter of the nonfunctioning ventriculo-atrial shunt in the right heart chambers impinged into the tricuspid valve apparatus, interfering with the opening of the valve and causing severe tricuspid stenosis (Figs. 1,2, movie clip S1). The patient was referred for surgical consultation but the operative risk was considered too high and the patient was treated conservatively. Case 102: A 75-year-old man with end-stage renal failure underwent left brachio-axillary arteriovenous grafting for hemodialysis. After several days thrombectomy was performed due to graft thrombosis, and a new communication between the radial artery and the brachio-axillary graft was created. On the next day, recurrent thrombosis of the graft occurred. Thrombectomy was performed where intra-operative angiography revealed stenosis of the venosus anastomosis and percutaneous angioplasty with stent implantation was contemplated. Subsequent angiography revealed migration of the stent into the right subclavian vein. An additional stent was inserted into the venous anastomosis. Angiography confirmed patency and a normally functioning graft. Follow-up chest x-ray was suspicious for migration

Figure 1. Case 101. A distal catheter of an old venticuloatrial shunt migrated into the right ventricle through the tricuspid valve.

Figure 2. Case 101. Continuous-wave Doppler across the tricuspid valve revealed severe tricuspid stenosis, caused by an old migrated atrioventricular shunt.

of the stent into the right heart chambers. Echocardiographic examination confirmed the presence of the stent in the right ventricle (Fig. 3, movie clip S2), entrapped within the tricuspid valve chords. Endovascular removal of the stent through the jugular vein was attempted, but the stent was impinged in the tricuspid valve apparatus. Surgical removal of the stent was recommended but the family refused. Case 103: A 19-year-old man was admitted for chest pain. He had undergone nephrectomy and repair of the abdominal aorta, due to a shotgun sequelae, 3 months before admission. Echocardiographic examination revealed an echogenic mass in the right ventricle with a sharp contour entrapped within the cords of the tricuspid valve, which was diagnosed as a bullet (Fig. 4, movie clip S3). The patient was referred for surgery and was operated successfully. The bullet was believed to have reached the right ventricle through the inferior vena cava.

Figure 3. Case 102. Migrated stent is seen in right ventricle.

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Figure 4. Case 103. Bullet in the right ventricle, impinged in chords of the tricuspid valve.

Case 104: A 60-year-old man with a history of hypertension and peripheral vascular disease underwent echocardiograpy before elective cholecystectomy. Ambulatory echocardiographic examination revealed a bright shadow in the right atrium, compatible with an electrode or wire (Fig. 5, movie clip S4). Subsequent detailed medical history revealed a recent peripheral vascular angiography 1 month prior. Chest x-ray revealed a long wire which reached the right atrium through the right femoral vein and inferior vena cava. Endovascular removal of the wire failed and the patient underwent surgical removal of this wire with exploration of the inferior vena cava. Discussion: Foreign bodies can reach the heart by direct penetration due to local trauma or through intravenous migration or may remain in the heart after medical procedures. Most common foreign bodies that reach the heart by local penetration are bullets, shrapnel, and circular saw fragments. Fragments of catheters, needles, inferior vena cava filters reach the right heart by migration through the venous system. Migration of inferior vena cava filters or their limbs 1–12 are usually symptomatic (12 of 14 cases), and may occur a long time after the insertion of the filter—in 1 patient 4 years following the procedure.8 It was the cause of cardiorespiratory arrest in 3 out of 14 patients,10,11 and was accompanied by ventricular fibrillation and death in 2 out of 14 patients.10,12 Migrated inferior vena cava filters resulted in the highest percent of death [50%] among the reported 104 patients. In 13 cases, migration of devices for the treatment of hydrocephalus was found.13–23 Migrated ventriculo-atrial shunts commonly occur many years after the insertion. In 2 of 4 patients with migrated ventriculo-atrial catheter severe 368

tricuspid stenosis may occur. Among the 8 patients with migrated ventriculo-peritoneal shunt, migration occurred shortly after insertion in 7 patients, and often was accompanied by neurological symptoms of shunt dysfunction. In 1 patient, staphylococcal sepsis occurred,20 in another abdominal hernia was found at the site of the incision.22 The presumed mechanism for migration might have been through injury to the internal/external jugular vein during the tunneling and propagation into the heart due to negative inspiratory pressure.17–22 Among the 9 cases, migrated catheters and devices for chemotherapy24–30 were mostly found located in the right heart chambers causing complications. Larger devices than catheters and migrated stents31–40 cause symptoms more often than catheters and are discovered shortly after insertion, between 1 day and 1 year. Cardiac injury is more extensive in the aorto-right atrial fistula with a perforation of the interatrial septum (2 patients) and 35,36 bloody pericardial effusion in 1.35 Severe tricuspid regurgitation with right heart failure occurred due to damage of the tricuspid valve with a migrated Wallstent in 2 cases.34,40 Other devices41–49 may have been left in the heart or may have been dislodged and can be asymptomatic or cause devastating complications such as Candida endocarditis of the tricuspid valve45 or a broken stylet retained in the interatrial septum.13 Percutaneous vertebroplasty is an effective, minimally invasive procedure for the treatment of osteoporotic and metastatic vertebral fractures. During this procedure, acrylic cement is injected into the vertebral body, rich blood vessels and leakage of acrylic cement through the paravertebral venous plexus is not rare. Through the inferior vena cava acrylic cement may reach the heart and form fish bone–like or catheter-like structures that can damage the heart. There were 5 cases of acrylic cement embolism among the 104 cases presented here, where 2 patients developed pulmonary embolism,50,53 1 bloody pericardial effusion,51 1 myocardial infarction,54 and 1 with rapid atrial flutter, congestive heart failure and moderate-severe tricuspid regurgitation.52 In another patient55 other acryl-based substances, such as histoacryl glue was used for the treatment of bleeding from varices during gastroscopy leak and through systemic venous circulation that reached the right atrium. Radioactive seeds implanted during transperineal interstitial brachytherapy of the prostate56 were found in the heart 1 year after the procedure and were managed conservatively. Of 49 radioactive seeds 3 migrated to the heart.

Foreign Body in the Heart

Figure 5. Case 104. A. Echocardiography. A tip of forgotten wire seen in the right atrium [arrow]. B, C, D. Chest x-ray. A long wire from the right femoral vein through the inferior vena cava reached the right atrium.

Pacemaker leads,57–60 usually epicardial, may migrate to the heart where they are usually removed after cardiac surgery when the patient is stable. When the surgeon feels that further pacing may be required, these leads are clipped in place and may migrate.59 Of the 5 patients with migrated pacemaker leads, 4 had been epicardial. Migration occurred between 3 months –13 years. In 1 patient, infected migrated pacemaker leads resulted in staphylococcal endocarditis of the pulmonic valve, severe pulmonary HPTN, severe tricuspid regurgitation, dyspnea, and congestive heart failure, while 2 patients underwent surgical removal.

Sternal struts /wire post–Ravitch surgery for correction of pectus excavatum and post-CABG have penetrated into the heart and required surgery.61–63 Kirshner wire for fixation of pelvis64 and after fixation of the femor65 migrated to the right ventricle. Some sharp objects, such as needles and tattoo needles may penetrate the human body.42,66–74 These require surgical removal. Bullets or shrapnel have been found in 9 out of 104 patients, 9%.42,75–77 5 out of 9 were asymptomatic and anatomically stable and treated conservatively and 4 patients underwent surgery. 369

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Conclusion: Foreign bodies in the heart may present a wide variety of symptoms and clinical presentations. Physicians should be aware of this rare and peculiar complications which may be fatal. Larger devices may result in more severe complications. References 1. Arjomand H, Surabhi S, Wolf NM: Right ventricular foreign body: Percutaneous transvenous retrieval of a Greenfield filter from the right ventricle–a case report. Angiology 2003;54:109–113. 2. Mohan G, Kasmani R, Okoli K, et al: Right atrial foreign body: Transvenous migration of Greenfield filter. Interact Cardiovasc Thorac Surg 2009;8:245–246. 3. Queiroz R, Waldman DL: Transvenous retrieval of a Greenfield filter lodged in the tricuspid valve. Cathet Cardiovasc Diagn 1998;44:310–312. 4. Agrawal H, Bishop CI, Wali S: Inferior vena cava filter fracture mimicking a myocardial infarction. Proceedings of UCLA Healthcare 2013;17: [Epub]. 5. Baik P, Fourzali R, Salsamendi J, et al: Transventricular migration of an inferior vena cava filter limb. Ann Thorac Surg 2014;97:343. 6. Peters MN, Khazi Syed RH, Katz MJ, et al: Inferior vena cava filter migration to the right ventricle causing nonsustained ventricular tachycardia. Tex Heart Inst J 2013;40:316–319. 7. Jassar AS, Nicotera SP, Levin N, et al: Inferior vena cava filter migration to the right ventricle. J Card Surg 2011;26:170–172. 8. Kalavakunta JK, Thomas CS, Gupta V: A needle through the heart: Rare complication of inferior vena caval filters. J Invasive Cardiol 2009;21:E221–E223. 9. Janjua M, Omran FM, Kastoon T, et al: Inferior vena cava filter migration: Updated review and case presentation. J Invasive Cardiol 2009;21:606–610. 10. Emaminia A, Fedoruk LM, Hagspiel KD, et al: Inferior vena cava filter migration to the heart. Ann Thorac Surg 2008;86:1664–1665. 11. Gelzinis T, Subramaniam K, Katz WE, et al: Intracardiac migration of retrievable vena cava filter. J Cardiothorac Vasc Anesth 2009;23:381–383. 12. Haddadian B, Shaikh F, Djelmami-Hani M, et al: Sudden cardiac death caused by migration of a TrapEase inferior vena cava filter: Case report and review of the literature. Clin Cardiol 2008;31:84–87. 13. Lillehei CW, Bonnabeau RC, Jr, Grossling S: Removal of iatrogenic foreign bodies within cardiac chambers and great vessels. Circulation 1965;32:782–787. 14. Akram Q, Saravanan D, Levy R: Valvuloplasty for tricuspid stenosis caused by a ventriculoatrial shunt. Catheter Cardiovasc Interv 2011;77:722–725. 15. Mujanovic E, Bergsland J, Jurcic S, et al: Calcified right atrial and pulmonary artery mass after ventriculoatrial shunt insertion. Med Arh 2011;65:363–364. 16. Mori T, Arisawa M, Fukuoka M, et al: Management of a broken atrial catheter migrated into the heart: A rare complication of ventriculoatrial shunt–case report. Neurol Med Chir 1993;33:713–715. 17. Fewel ME, Garton HJ: Migration of distal ventriculoperitoneal shunt catheter into the heart. Case report and review of the literature. J Neurosurg 2004;100(2 Suppl. Pediatrics):206–211. 18. Frazier JL, Wang PP, Patel SH, et al: Unusual migration of the distal catheter of a ventriculoperitoneal shunt into the heart: Case report. Neurosurgery 2002;51:819–822.

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19. Chong JY, Kim JM, Cho DC, et al: Upward migration of distal ventriculoperitoneal shunt catheter into the heart: Case report. J Korean Neurosurg Soc 2008;44:170–173. 20. Wei Q, Qi S, Peng Y, et al: Unusual complications and mechanism: Migration of the distal catheter into the heart–report of two cases and review of the literature. Childs Nerv Syst 2012;28:1959–1964. 21. Imamura H, Nomura M: Migration of ventriculoperitoneal shunt into the heart–case report. Neurol Med Chir (Tokyo) 2002;42:181–183. 22. Ryugo M, Imagawa H, Nagashima M, et al: Migration of distal ventriculoperitoneal shunt catheter into the pulmonary artery. Ann Vasc Dis 2009;2:51–53. 23. Hermann EJ, Zimmermann M, Marquardt G: Ventriculoperitoneal shunt migration into the pulmonary artery. Acta Neurochir (Wien) 2009;151:647–652. 24. Martins EC, Faria GB: Percutaneous retrieval of intracardiac foreign body with a novel technique. Arq Bras Cardiol 2007;88:e179–e181. 25. Sattari M, Kazory A, Phillips RA: Fracture and cardiac migration of an implanted venous catheter. Interact Cardiovasc Thorac Surg 2003;2:532–533. 26. Kapadia S, Parakh R, Grover T, et al: Catheter fracture and cardiac migration of a totally implantable venous device. Indian J Cancer 2005;42:155–157. 27. Chang CL, Chen HH, Lin SE: Catheter fracture and cardiac migration–an unusual fracture site of totally implantable venous devices: Report of two cases. Chang Gung Med J 2005;28:425–430. 28. Choksy P, Zaidi SS, Kapoor D: Removal of intracardiac fractured port-A catheter utilizing an existing forearm peripheral intravenous access site in the cath lab. J Invasive Cardiol 2014;26:75–76. 29. Shailesh S, Babu MN, Gowrishankar BC, et al: Delayed cardiac migration of totally implantable central venous access catheter. Clin Cancer Invest J, 2014;3:182–184. 30. Ribeiro RC, Monteiro AC, Menezes QC, et al: Totally implantable catheter embolism: Two related cases. Sao Paulo Med J 2008;126:347–349. 31. Bani-Hani S, Showkat A, Wall BM, et al: Endovascular stent migration to the right ventricle causing myocardial injury. Semin Dial 2012;25:562–564. 32. Deepak SM, Sookur D, Levy RD: Percutaneous retrieval of migrated femoral vein stent from the right heart. Br J Cardiol 2008;15:55–56. 33. Kobayashi D, Singh HR, Turner DR, et al: Transcatheter retrieval and repositioning of embolized stent from the right ventricle in an infant. Tex Heart Inst J 2012;39:639– 643. 34. Cohen MH, Kyriazis DK: Wallstent migration into the right ventricle causing severe tricuspid regurgitation and right ventricular perforation. Tex Heart Inst J 2012;39:271–272. 35. Lin X, Fang L, Wang Y: Multiple heart injuries caused by fracture and migration of the inferior vena stent. Eur Heart J 2013;34:625.  pez MT, Martın-Trenor A, Mastrobuoni S, et al: 36. Barrio-Lo Iatrogenic atrial septal defect and aortoatrial fistula in a patient with endovascular prosthesis in the inferior vena cava. Ann Thorac Surg 2012;93:e23–e25. 37. Hsiung MC, Chang YC, Wei J, et al: Embolization of the stent to the right heart after a motor vehicle accident. Echocardiography 2010;27:587–589. 38. Kaneko K, Hirono O, Yuuki K, et al: Complete atrioventricular block due to venous stent migration from innominate vein to right ventricle: A case report. J Cardiol 2009;53:453–457. 39. Chen S, Zhang H, Tian L, et al: A stranger in the heart: LRV stent migration. Int Urol Nephrol 2009;41:427–430. 40. Linka AZ, Jenni R: Migration of intrahepatic portosystemic stent into right ventricle: An unusual cause of tricuspid regurgitation. Circulation 2001;103:161–162.

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41. Choi CH, Elahi MM, Konda S: Iatrogenic retained foreign body in the right atrium. Lessons to Learn. Inter J Surg Case Rep 2013;4:985–987. 42. Actis Dato GM, Arslanian A, Di Marzio P, et al: 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. 43. Khaja F, Lakier J: Foreign body retrieval from the heart by two catheter technique. Cathet Cardiovasc Diagn 1979;5:263–268. 44. Lijoi A, Barberis L, Passerone GC, et al: Removal of iatrogenic foreign bodies within cardiac chambers with a new snare catheter. Tex Heart Inst J 1982;9:153–156. 45. Wellmann KF, Reinhard A, Salazar EP: Polyethylene catheter embolism. Review of the literature and report of a case with associated fatal tricuspid and systemic candidiasis. Circulation 1968;37:380–392. 46. Rossi P: “Hook catheter”, technique for transfemoral removal of foreign body from right side of the heart. Am J Roentgenol Radium Ther Nucl Med 1970;109:101–106. 47. Henley FT, Ballard JW: Percutaneous removal of flexible foreign body from the heart. Radiology 1969;92:176. 48. Daga O, Talay S, Kaygin MA, et al: A rare complication of PDA coil occlusion: Rapidly migrating foreign body from femoral vein to right ventricle. J Med Cases, 2013;4:139– 141. 49. Dias-Filho AC, Coaracy GA, Borges W: Right atrial migration of nephrostomy catheter. Int Braz J Urol 2005;31:470–471. 50. Eun Lee SE, Chang S-A, Kim M-S, et al: Acrylic cement foreign body and thrombus in right atrium causing pulmonary embolism after percutaneous vertebroplasty. Korean Circ J 2006;36:713–715. 51. Park JH, Choo SJ, Park SW: Images in cardiovascular medicine. Acute pericarditis caused by acrylic bone cement after percutaneous vertebroplasty. Circulation 2005;111: e98. 52. Kim HT, Kim YN, Shin HW, et al: Intracardiac foreign body caused by cement leakage as a late complication of percutaneous vertebroplasty. Korean J Intern Med 2013;28:247–250. 53. Llanos RA, Viana-Tejedor A, Abella HR, et al: Pulmonary and intracardiac cement embolism after a percutaneous vertebroplasty. Clin Res Cardiol 2013;102:395–397. 54. Grifka RG, Tapio J, Lee KJ: Transcatheter retrieval of an embolized methylmethacrylate glue fragment adherent to the right atrium using bidirectional snares. Catheter Cardiovasc Interv 2013;81:648–650. 55. Miyakoda K, Takedatsu H, Emori K, et al: N-butyl-2-cyanoacrylate (histoacryl) glue in the right atrium after endoscopic injection for a ruptured duodenal varix: Complication of histoacryl injection. Dig Endosc 2012;24: 192. 56. Miyazawa K, Matoba M, Minato H, et al: Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: Analysis of its incidence and risk factors. Jpn J Radiol 2012;30:635–641. 57. Hong SN, Rosenzweig B, Crooke GA, et al: Inside and out: An epicardial lead gone astray. Tex Heart Inst J 2011;38:204–205. 58. Hong SN, Rosenzweig B, Crooke GA, et al: Functionless retained pacing leads in the cardiovascular system. A complication of pacemaker treatment. Br Heart J 1985;54:76–79. 59. Spellberg RD, Dobkin JE, Soleymani S: Intracardiac migration of operatively placed epicardial pacing leads. Ann Thorac Surg 2012;93:1713–1715. 60. Sheikh M, Bruhl SR, Omer S, et al: Transmyocardial voyage of a temporary epicardial lead: An unusual long-term complication. Pacing Clin Electrophysiol 2012;35:e185– e186.

61. Zhang R, Hagl C, Bobylev D, et al: Intrapericardial migration of dislodged sternal struts as late complication of open pectus excavatum repairs. J Cardiothorac Surg 2011;6:1–4. 62. Lee SH, Cho BS, Kim SJ, et al: Cardiac tamponade caused by broken sternal wire after pectus excavatum repair: A case report. Ann Thorac Cardiovasc Surg 2013;19:52– 54. 63. Levisman J, Shemin RJ, Robertson JM, et al: Migrated sternal wire into the right ventricle: Case report in cardiothoracic surgery. J Card Surg 2010;25:161–162. 64. Park SY, Kang JW, Yang DH, et al: Intracardiac migration of a Kirschner wire: Case report and literature review. Int J Cardiovasc Imaging 2011;27(Suppl. 1):85–88. 65. Ono M, Goerler H, Boethig D, et al: Surgical removal of Kirschner wire from the right ventricle, migrated from the femur. Eur J Cardiothorac Surg 2010;37:486. 66. Harrer J, Holubec T, Brtko M: A foreign body in the heart due to an unusual injury. Ann Thorac Surg 2009;88:985–987. 67. Pesenti Rossi D, Balderacchi U, Chhuon C, et al: Love of children touched mother’s heart. Circ Cardiovasc Interv 2012;5:e51–e52. 68. Zhang C, Hu J, Ni Y, et al: Successful salvage of post-traumatic metallic foreign body partially retained in the posterior papillary muscle of the left ventricle. Interact Cardiovasc Thorac Surg 2006;5:507–508. 69. Das D, Rana S, Singh J, et al: Unusual intrapulmonary and intramyocardial foreign body: A case report. Int J Thorac Cardiovasc Surg 2006;9: [Epub]. 70. Liu H, Juan YH, Wang Q, et al: Foreign body venous transmigration to the heart. QJM 2014;107:743–745. 71. Rinaldi JP, Latcu DG, Dor V, et al: Asymptomatic intracardiac migration of a sharp foreign body. Arch Cardiovasc Dis 2011;104:59–60. 72. Bahcßıvan M, Duran L, C ß elik S, et al: Migration of a foreign body to the right ventricle following traumatic penetration to the right subclavian vein. Anadolu Kardiyol Derg 2012;12:531–532. 73. Steiner J, Dhingra R, Devries JT: Needle in the haystack: Purulent pericarditis from injection drug use. Catheter Cardiovasc Interv 2012;80:493–496. 74. Neely D, Jeganathan R, Campalani G: Transcaval migration of an acupuncture needle from the abdominal cavity to the heart. J Card Surg 2010;25:654–656. 75. Kones RJ, Phillips JH: Foreign body of the heart complicated by papillary muscle necrosis located by echocardiography: Report of a case and review of the literature. Chest 1972;62:52–57. 76. Levi B, Sainsbury CR, Scharf DL: Delayed shotgun pellet migration to the right ventricle. Clin Cardiol 1985;8:367– 371. 77. Bedi HS, Sharma VK, Kasliwal RR, et al: Foreign body in the heart. Tex Heart Inst J 1997;24:140–141.

Supporting Information Additional Supporting Information may be found in the online version of this article: Movie clip S1. Case 101. A distal catheter of the old venticulo-atrial shunt migrated into the right ventricle through the tricuspid valve. Movie clip S2. Case 102. Migrated stent is seen in the right ventricle. Movie clip S3. Case 103. Bullet in the right ventricle, impinged in chords of tricuspid valve. Movie clip S4. Case 104. A tip of forgotten wire seen in the right atrium.

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