To the Editor:
Heart lesions produced by the introduction of sewing needles into the thorax by people with autoagressive behavior patterns are very rare.1-4 Such patients usually suffer psychiatric disorders and present at hospital manifesting that they have introduced a foreign object into their chest, or with chest pain, dyspnea and sometimes pneumothorax. We recently treated a female drug addict with psychiatric problems who had managed to introduce a sewing needle into the myocardium. The migration of such objects into the heart chambers can cause intramural hematomas, tamponade, infection, embolism, valve dysfunction and death, and their extraction is recommended.3,4
The present patient was 44 years old, had a background of schizophrenia and drug abuse, and had been institutionalized after a suicide attempt. She was admitted to our hospital after having inserted a sewing needle into the precordium. She complained of pain in the fifth midclavicular intercostal space, where an area of ecchymosis was visible. A physical examination showed several scars on the left arm. Radioscopy revealed a metallic object that moved with the cardiac silhouette. Echocardiography and computed tomography showed a needle to be lodged in the heart (Figure 1).
Figure 1. Tomographic image of the needle inside the heart.
Figure 2. Extraction of the needle following left ventriculotomy after the establishment of extracorporeal circulation.
Since the patient was hemodynamically stable, videothoracoscopic exploration and extraction of the object was attempted, but this proved fruitless. Given the risk of migration and tamponade it was decided to undertake direct surgery. Following sternotomy, a hematoma was noticed on the back side of the left hemithorax and in the pericardial fat. Following pericardiotomy, a small serohematic hemorrhage and granuloma were seen on the anterior face of the left ventricle close to the left descending coronary artery. The remainder of the heart and the pericardial cavity were normal. Intraoperative radioscopy showed the needle to be in the left ventricle. The granuloma was explored, positioning the heart with a stabilizer (Octopus®). The dissection of the beating heart proved unfruitful, and given the danger of perforating the left ventricle the decision was made to continue with extracorporeal circulation and cardioplegic arrest. Figure 2 shows the dissection of the granuloma and the extraction of a 7 cm long sewing needle (this needle was completely within the myocardium; the figure shows it partially extracted). Ventricular closure was performed with 2 Teflon patches. The patient progressed satisfactorily with no complications.
Heart lesions caused by the introduction of pins or needles in an attempt to inflict self-injury have been described only on very few occasions. Such self-mutilatory behavior has been observed in patients with schizophrenia, depression, and in the mentally disabled. As in the present case, drug or alcohol abuse increases the probability of such behavior. In published cases, these needles have been found free in the pericardial cavity or in the left ventricle, extraction being performed with or without extracorporeal circulation as required.1,5 Although some authors have suggested that these objects might be removed by performing a small anterior thoracotomy without the help of extracorporeal circulation,5 in the present case, conventional midline sternotomy was decided upon following the failure of thoracoscopy. Intraoperative radioscopy was successful in finding the end of the needle, thus showing where ventriculotomy was required.