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C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N . T H I S I S A N O P E N A C C E S S A R T I C L E U N D E R T H E

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CASE REPORT

CLINICAL CASE

Clinical Pulp Fiction

First Multimodality Imaging of Needle Migration FromDistal Esophagus Into Ventricular Septum

Claire F. Woodworth, MD,a Susan M. Fagan, MD,b Scott R. Harris, MD,a Corey Adams, MDc

ABSTRACT

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A 21-year-old woman self-ingested an 18-gauge needle that perforated the distal esophagus into the left inferior

ventricular myocardium, with migration into the septum. Radiography, computed tomography, and echocardiography

imaging characterized the needle’s location. Following an initial endoscopy and pericardial tamponade

drainage, complete needle removal occurred via median sternotomy and cardiopulmonary bypass.

(Level of Difficulty: Intermediate.) (J Am Coll Cardiol Case Rep 2020;2:653–7) Crown Copyright © 2020 Published

by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the

CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

HISTORY OF PRESENTATION

A hemodynamically stable 21-year-old woman pre-sented to the emergency department after a poly-pharmacy overdose. She also ingested severalunfolded paperclips and an 18-gauge peripheralintravenous (IV) angiocatheter needle. Abdominalseries radiography revealed several linear radiopaqueforeign bodies (FBs) projecting over the inferior epi-gastrium (Figure 1). Approximately 24-h post-ingestion, the patient reported acute severe chest

EARNING OBJECTIVES

To discuss imaging modalities used in theevaluation of a cardiac FB.To review when urgent surgery is indicatedfor a cardiac FB.To understand common and uncommoncardiac FBs.

N 2666-0849

m the aDiscipline of Radiology, Faculty of Medicine, Memorial Universi

brador, Canada; bDiscipline of Cardiology, Faculty of Medicine, Me

wfoundland and Labrador, Canada; and the cDiscipline of Cardiac Surge

wfoundland, St. John’s, Newfoundland and Labrador, Canada. The auth

evant to the contents of this paper to disclose.

e authors attest they are in compliance with human studies committe

titutions and Food and Drug Administration guidelines, or patient consen

CC: Case Reports author instructions page.

nuscript received December 4, 2019; revised manuscript received Januar

pain and shortness of breath after several episodes ofemesis. She became hypotensive (90/60 mm Hg) andtachycardic (144 beats/min). Her physical examina-tion was normal.

MEDICAL HISTORY

The patient had no previous cardiothoracic disease.

DIFFERENTIAL DIAGNOSIS

Given the patient’s emesis and chest pain, gastroin-testinal perforation was considered highly probable(perhaps a Mallory-Weiss tear or Boerhaave syn-drome). With the documented FB ingestion, perfora-tion secondary to FB penetration was also considered.

INVESTIGATIONS

A portable chest radiograph showed migration of alinear radiopaque FB to the distal esophagus but no

https://doi.org/10.1016/j.jaccas.2020.01.013

ty of Newfoundland, St. John’s, Newfoundland and

morial University of Newfoundland, St. John’s,

ry, Department of Surgery, Memorial University of

ors have reported that they have no relationships

es and animal welfare regulations of the authors’

t where appropriate. For more information, visit the

y 13, 2020, accepted January 16, 2020.

FIGUR

Linear

gastriu

paperc

ABBR EV I A T I ON S

AND ACRONYMS

CT = computed tomography

IV = intravenous

FB = foreign body

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free air (Figure 2A). Emergent computed to-mography (CT) imaging of the chest andabdomen found an w5.5-cm linear hyper-attenuating density. This extended from thedistal esophagus anterosuperiorly throughthe pericardium into the left inferior ven-

tricular myocardium (Figures 2B and 2C). A new peri-cardial effusion had Hounsfield units of w40 to 45 inkeeping with blood products.

Acute cardiac tamponade caused significant he-modynamic stress. The patient’s electrocardiogramrevealed electrical alternans with sinus tachycardia. Atransthoracic echocardiogram showed a large peri-cardial effusion with diastolic collapse of the rightatrium and right ventricular dimpling suggestive oftamponade physiology (Video 1). Respiratory varia-tion with Doppler inflow reinforced significant he-modynamic stress (Figure 3). The inferior vena cavawas dilated with a blunted response to respiratoryvariation. Best characterized on the subcostal views, athin echogenic/metallic object was seen traversingthe pericardial space into the myocardium. Mobilitywith ventricular contraction suggested an FB intrinsicto the heart (Video 2).

MANAGEMENT

Hemodynamic instability necessitated the decision todrain the pericardial effusion and explore the

E 1 Post-ingestion Abdominal Series Radiography

radiopaque foreign bodies project over the inferior epi-

m. Different caliber radiodensities represent unfolded

lips (arrowheads) and an 18-gauge needle (arrow).

gastrointestinal tract by using an upper endoscopytechnique. Successful drainage of the pericardialeffusion by a minimally invasive left anterior thora-cotomy revealed blood in the pericardial space withno active source of bleeding. The upper endoscopyresulted in removal of all paper clips; however, an 18-gauge needle was not located, nor was there evidenceof gastroesophageal perforation.

Taken into consideration that we did not locate aneedle, a portable chest radiograph was performedimmediately post-procedure. Overlying the cardiacsilhouette, a persistent linear radiopaque density wasreoriented in more of a transverse plane (Figure 4A).Repeat CT examination showed further migrationinto the heart with lodgment of the presumed needleinto the interventricular septum (Figures 4B and 4C).This finding prompted emergent surgery, and thepatient was returned to the operating room for a fullmedian sternotomy and exploration. Cardiopulmo-nary bypass was established via aorto-bicaval can-nulation, and cardioplegic cardiac arrest wasperformed. Initial incision in the right atrium allowedexploration of the right atrium and right ventricle.There was no evidence of a needle in these cavities. Atransseptal approach was performed through thefossa ovalis into the left atrium. Palpation revealed ahard object in the septum. By digital manipulation,the 18-gauge peripheral IV angiocatheter needle waslocated in the left ventricle at the height of the pos-terior lateral papillary muscle. This was carefullyremoved en bloc (Figure 5). Defects in the septum andright atrium were closed, and the patient was weanedoff cardiopulmonary bypass. Transesophageal echo-cardiography showed a small, nonhemodynamicallysignificant ventricular septal defect and no retainedFB material, which was confirmed with a post-operative chest radiograph.

DISCUSSION

We present the first multimodality serial imaging of aself-ingested needle that migrated across the esoph-agus into the ventricular septum. The patientrequired emergent intervention after she developedcardiac tamponade caused by the needle’s initialperforation of the myocardium. Apart from symp-tomatology, early surgical removal was also indicatedgiven the potential direct inoculation of the gastro-esophageal flora into the myocardium. Radiographs,CT imaging, transthoracic echocardiogram, andtransesophageal echocardiogram interrogated the FBlocation throughout management. In our case,prompt removal via upper endoscopy was unsuc-cessful due to intracardiac migration of the needle,

FIGURE 2 Radiologic Investigations After Clinical Deterioration

(A) Portable chest radiograph revealed a linear radiopaque density projecting over the distal esophagus (arrow). (B) Axial computed tomography imaging showed new

complex pericardial fluid. (C) Sagittal oblique computed tomography imaging best characterized the linear hyperattenuating foreign body’s course from the distal

esophagus anterosuperiorly through the pericardium to the inferior left ventricular myocardium.

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necessitating full median sternotomy and cardiopul-monary bypass.

Cardiac FBs are rare; however, when they do occur,they are often the result of trauma, IV drug abuse, or

FIGURE 3 Transthoracic Echocardiographic Interrogation of the Mit

Respiratory variation with Doppler inflow reinforced significant hemody

iatrogenic causes (1). FBs can directly penetrate intothe myocardium or embolize to the heart through thevenous system. The location of a cardiac FB is variableand mechanism-specific; objects causing direct injury

ral Valve

namic stress.

FIGURE 4 Radiologic Investigations After Upper Endoscopy

(A) A portable chest radiograph showed a persistent linear radiopaque density overlying the cardiac silhouette, slightly changed in position from previous (arrow). Axial

oblique (B) and sagittal oblique (C) computed tomography images revealed migration of the hyperattenuating foreign body to the interventricular septum.

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are likely to be partially or fully embedded within themyocardium,while those arriving from the systemic orpulmonary veins can be intracavitary. Foreign bodiesthat reach the ventricles via the vasculature maybecome entrapped in the endocardial trabeculations

FIGURE 5 Intraoperative Photographs

(A) View of the ingested 18-gauge needle through the right atrium durin

the patient’s cardiac septum.

and encrusted with fibrous tissue or re-embolize to thepulmonary or systemic circulation (2). In the acutephase, intracardiac migration of sharp objects shouldbe anticipated due to the forces of respiratory andcardiac movements (3). Cardiac FBs can be diagnosed

g removal. (B) Ruler alongside the needle that was dislodged from

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immediately after an injury, later post-complication ifa patient becomes symptomatic, or even incidentallyduring evaluation for another condition. Late compli-cations include pericarditis, cardiac tamponade, andendocarditis.

The literature supports managing cardiac FBs on anindividual basis, including treating conservatively orwith a tailored surgical approach depending on theclinical scenario. There are no guidelines detailingwhen an operative or conservative approach is war-ranted. Reported indications for removal include thepatient’s symptoms as well as the associated risks ofinfection, embolization, arrhythmia, and furtherstructural damage due to object migration/erosion(1–4). Numerous case reports describe cardiac FBsresulting from external penetrating trauma andembolization, but there is only one other reportedinstance of cardiac injury due to migration of aswallowed needle (5). In that case, a female prisonerhad swallowed a 5-cm sewing needle 7 days beforeshe died of cardiac tamponade. Although it followed asimilar anatomic course, that needle was not charac-terized on radiological imaging as in our case (only 2radiographs were performed).

FOLLOW-UP

The patient’s post-operative course was complicatedby aspiration pneumonia and bacteremia (Entero-coccus faecalis). Given the risk of gastroesophagealflora in the heart, the patient was treated with dap-tomycin and piperacillin-tazobactam. Early pericar-dial drainage appeared purulent, but tests of culturedoperating room tissue were negative. The patientprogressed on a cardiovascular surgery recoverypathway. Follow-up revealed no conduction abnor-mality or valvular dysfunction.

CONCLUSIONS

Multimodality imaging is crucial in characterizingcardiac FB location and assisting in surgical removal.

ADDRESS FOR CORRESPONDENCE: Dr. CoreyAdams, Discipline of Cardiac Surgery, Department ofSurgery, Memorial University of Newfoundland, c/oHealth Sciences Centre, 300 Prince Philip Drive, St.John’s, Newfoundland and Labrador A1B 3V6,Canada. E-mail: cadams@munmed.ca.

RE F E RENCE S

1. Actis Dato GM, Arslanian A, Di Marzio P,Filosso PL, Ruffini E. Posttraumatic andiatrogenic foreign bodies in the heart: reportof fourteen cases and review of the litera-ture. J Thorac Cardiovasc Surg 2003;126:408–14.

2. Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles. A review of the literatureand personal experience. Ann Surg 1990;211:639–47.

3. Perrotta S, Perrotta A, Lentini S. In patients withcardiac injuries caused by sewing needles is thesurgical approach the recommended treatment?Interact Cardiovasc Thorac Surg 2010;10:783–92.

4. Thanavaro KL, Shafi S, Roberts C, et al. An un-usual presentation of chest pain: needle perfora-tion of the right ventricle. Heart Lung 2013;42:218–20.

5. Vesna D, Tatjana A, Slobodan S, Slobodan N.Cardiac tamponade caused by migration of a

swallowed sewing needle. Forensic Sci Int 2004;139:237–9.

KEY WORDS computed tomography,echocardiography, imaging, tamponade,treatment

APPENDIX For supplemental videos,please see the online version of this article.