Case report:
A 28-year-old male presented with acute pressure-like chest pain and dyspnea that began
suddenly the night prior to arrival after using crystal methamphetamine, with no aggravating
or alleviating factors and no other associated symptoms. On physical examination patient was
afebrile 36.5°C, tachycardic ranging 115-125, with a respiratory rate 18-30, and blood
pressure ranging wildly from 131/117 at highest to below 90/60. Patient was anxious, in acute
distress, diaphoretic with distant heart sounds, and rapid faint distal pulses.The patient had known history of metabolic syndrome, untreated hepatitis C, and intravenous drug abuse with methamphetamines and heroin. He had two needles break off into his right arm 2 years prior to this event. He was taking suboxone for drug abuse. He had no prior surgeries or other known medical conditions.
Initial troponin was normal (<0.012 ng/mL), Initial CXR was unrevealing. EKG in ED demonstrated subtle ST elevations in the inferolateral leads which led to a concern for STEMI, so a right and left coronary angiogram and left ventriculogram were performed with multiple views taken. See figures1-5. These demonstrated normal coronary anatomy with mild atherosclerosis, an EF of 55%, and mild inferior hypokinesis. It appeared as if there was a foreign body inside the heart and so a stat CT scan was ordered to rule this out, and an echocardiogram was obtained to rule out tamponade. See figures 6-8. CT scan confirmed presence of needle in the right ventricle, and echocardiogram confirmed presence of tamponade with partial right ventricle diastolic collapse.
Given sudden hypotension and tachycardia, the patient was given rapid intravenous fluids to temporize blood pressure while being rushed to the operating room where an emergent median sternotomy was performed. During this procedure 500 ml of fluid was drained from within the pericardial sac. Upon exploration of the mediastinum a needle was found in the fibrous scarring of the right ventricular epicardium (Figure 9 ). The needle had burrowed through the right ventricular cavity to the outer surface of the right ventricular epicardium. A second needle was not found; thus, the pericardial sac was copiously irrigated, three chest tubes were placed, and the sternum was closed. The patient was then placed on cefuroxime for 48 hours for concern for possible endocarditis, but given normal white blood cell count, lac of fever, improving chest pain, and negative blood cultures at 48 hours, infectious disease consult deemed it ok to stop antibiotics. A CT of the RUE and chest were obtained to confirm that there was not a second needle in the heart. RUE CT demonstrated a needle within the antecubital fossa that was stable and not damaging nearby structures, given this it was decided to not remove the needle and observe as outpatient. The three chest tubes drained an additional 500 ml of fluid before being removed and patient was discharged with close follow up on post-operative day 4 after an uneventful post-operative course. Follow up chest x-ray at one week and one month did not show any significant acute findings. Patient followed up in surgery clinic one month after discharge and did not have any acute concerns.