Introduction

The management of retained missiles in the heart has remained controversial probably because of limited number of patients seen by each investigator and due to the differences in retained missile.₁ Pulmonary parenchymal foreign bodies are mostly introduced as a result of trauma.₂ The nature of these foreign bodies are varied, ranging from pellets,₃ bullets,₁ shrapnels,₁,₇ icepicks,₄ pencil₂ and so on. We report an extremely unusual case of a retained foreign body at two places, intrapulmonary and intramyocardial simultaneously.

Case Report

A 17 year old man was referred to our institution following an assault with hypodermic needles in a doctor's clinic. The patient walked into the emergency unit of our hospital two days after the injury. The patient was initially treated at a different hospital where the entry wound was explored without any success. First chest x-ray done there revealed a single needle near the lower end of sternum, lying in anterior chest wall. Repeat chest x-ray (posterior-anterior and lateral views) done at our institute showed two needles, one at the lower end of sternum and another in the left lung field, middle zone (Figure 1 and 2).

Figure 1

Figure 1 : Chest X-ray (PA view) showing needles (arrows)

Figure 2

Figure 2 : Chest X-ray (Lateral view) showing needles (arrows)

The needle at the lower end of sternum had migrated deeper as compared to the first x-ray. CT scan (Figure 3 and 4) of the chest revealed one of the needles embedded in the myocardium, while the second was visualised in the left lung parenchyma.

Figure 3

Figure 3 : CT Scan Lung showing needle (arrow)

Figure 4

Figure 4 : CT Scan Heart showing needle (arrow)

The patient was explored by a left anterolateral thoracotomy under general anaesthesia with double lumen endotracheal tube. The first needle could be localized only after deflating the left lung and was recovered from the upper lobe of left lung. On opening the pericardium, minimal pericardial fluid was found. A part of the second needle was seen protruding through the apex of the heart. It was also successfully recovered. The patient made an uneventful recovery and was discharged two days after surgery.

Discussion

Cardiac missile may remain in the heart after its direct entry or after an injury to a systemic or pulmonary vein and subsequent embolisation.₁,₅ Penetrating cardiac injuries usually cause severe cardiovascular compromise either from exsanguinating haemorrhage or cardiac tamponade. Various late clinical manifestations of retained missiles have been due to systemic or pulmonary embolisation of missile or thrombi, bacterial endocarditis, pericarditis, tamponade and conduction disturbances.₁ Diagnosis of cardiac foreign bodies may be suspected immediately after the injury or incidentally during investigation for another condition when the missile has remained silent for an extended time.₆ When diagnosed later, most cardiac foreign bodies have been entrapped by fibrous tissue and, if the patient is asymptomatic, do not cause particular harm. Finally in some cases, a patient becomes symptomatic many years after diagnosis of foreign body that had been treated conservatively. Treatment options including surgery or a conservative approach must be tailored case by case in relation to symptoms and possible associated risks.₁ The patients should be evaluated properly and missile located precisely by radiology, 2D and Doppler echocardiography or angiocardiography before undertaking definite surgery.₇ Intracavitary missiles or missiles partially embedded in the myocardium, particularly in the left side of heart, should be removed because of the risk of infection or embolisation.₁,₆

Pulmonary parenchymal foreign bodies are mostly introduced as a result of trauma.₂ CT scan has proved to be an expedient method for detecting foreign bodies in soft tissues including lung. Foreign bodies in lung warrant careful surgical removal to prevent any pulmonary parenchymal complications.

Simultaneous occurrence of foreign bodies in lung and heart has not been reported so far. In our case, the patient was taken up for surgery after localisation on X-ray and CT scan because needles have a high propensity to embolize and the intramyocardial needle was suspected to be in the apex of the heart. Both the intrapulmonary and intramyocardial needles were successfully removed and the patient made an uneventful recovery.

Correspondence to

Dr. Debasis Das Senior Resident Department of Cardiovascular & Thoracic Surgery PGIMER, Chandigarh 160012 E mail : dasdeba@yahoo.com