A Needle Infixed in the Heart MASSIMO GALLERANI, MD,* FABRIZIO FERRARI, MD,I GAETANO MAGENTA, MD,* GUGLIELMO BARBOSO, MD,::I: ANNA MARIA ANTONELLI, MD,:I: ROBERTO MANFREDINI, MD§ A 34-year-old man self-fixed a needle into his heart, in the interventricular septum. The foreign body was localized by X-ray, echocardiography,and computed tomography.At surgical opening of the pericardial lamina, the needlewas extractedwith no needof cuttingopen the cardiac muscle. (Am J Emerg Med 1998;16:662-663. Copyright © 1998 by W.B. Saunders Company) Penetrating cardiac trauma is classically associated with high mortality, and the majority of patients sustaining cardiac injury present to the emergency department (ED) in extremis or with signs of shock. However, a small percent- age may have no alteration in their vital signs. 1 These patients are exposed to delays in diagnosis or treatment, which may result in death that could have been preventable. We report a case of self-fixing of a needle in the heart. CASE REPORT A 34-year-old man with a history of opiod abuse and borderline personality disorder (ICD-10 F60.31) was admitted to our ED complaining of thoracic retrosternal pain of about 24 hours' duration. At clinical examination, blood pressure, pulse, and respirations were 120/70 mm Hg, 65 beats/min, and 26 breaths/rain, respec- tively. The patient showed evident signs of recent heroin ingestion. Clinical examination also found signs of previous self-harming attempts, eg, scars of wounds at the forearms and the wrists, and several slashes under the xiphoid zone. At the level of left parasternal region, in the 6th, 7th, and 8th intercostal spaces along an area of approximately 6 to ? centime- ters, signs of several pricks (about 10) were found. After repeated questioning, the patient reported that nearly 40 hours earlier, he had been playing a dangerous game in the company of other substance abusers, repeatedly self-fixing a darning needle in the precordium. He had been under the effects of both heroin and psychotropic drugs, and he did not remember the event clearly. The electrocardiogram showed sinusal rhythm with diffuse elevation of ST segment. Chest X-ray showed the presence of a metallic body, possibly a needle, casting on the cardiac area (Figure 1). Echocardiography showed cardiac chambers with normal volume and dimensions and normal contractility. More- over, apart from a little pericardial effusion, the image confirmed that in the antero-septal region of the right ventricle there was a foreign body with an appearance consistent with a metallic needle. Computed tomography (CT) showed a metallic needle 4 cm in length fixed in the interventricular region with apparent involve- ment of the septum. The metallic body seemed to protrude for several millimeters into the pericardial space (Figure 2). The patient was brought to a cardiosurgery center for an operation. At the opening of pericardial lamina, the needle appeared to be fixed about 1 cm from the anterior descending coronary and to protrude for about 2 mm from cardiac tissue. Thus, it was possible to extract the needle with no need of cutting the cardiac muscle. The patient was discharged 4 days later in good health, DISCUSSION Traumatic lesions of the heart are wrongly considered to occupy an insignificant place among cardiovascular dis- From the *Emergency Department and -i-Division of Cardiology, St Anna Hospital, Ferrara; the :~lnstitute of Cardiosurgery, University of Parma, Parma; and the §Section of First Internal Medicine, Depart- ment of Clinical and Experimental Medicine, University of Ferrara, Ferrara, Italy. Manuscript received April 1,1997; accepted May 13, 1997. Address reprint requests to Dr Gallerani, Emergency Department, St Anna Hospital, Corso Giovecca 203, 1-44100 Ferrara, Italy. Key Word: Needle, heart, cardiac injury. Copyright © 1998 by W.B. Saunders Company 0735-6757/98/1607-001058.00/0 662 FIGURE 1. Chest X-ray showing the presence of a metallic body in the cardiac area.