Discussion:
After an extensive literature search, we found 12 case reports
describing cardiac embolization of needle fragments in IV drug users
between 1988-2019.(3-14) Characteristics of these case reports including
chief complaint, cardiac complications and type of interventions
performed are noted in Table 1. Considering the number of IV drug users
and reported frequency of broken needle fragments by this population,
the low number of case reports of needle embolization to the heart in
this population is surprising. This could be due to multiple factors,
reluctance of this population to get medical attention, misdiagnosis
considering the asymptomatic nature in many cases etc. In IV drug users
presenting to the health care setting with chest pain, dyspnea etc,
special attention must be paid to the possibility of needle embolization
to the heart.
Here we have a very rare case of accidental needle loss in a patient’s
arm which then embolized to his myocardium and pericardium through his
venous system. Even more surprising is the fact that this patient did
not suffer from cardiac infection after the introduction of the Foreign
body. However as noted in other similar case reports in table 1, these
needles can be surprisingly well tolerated without symptoms for years,
and do not always need to be removed as long as the patient is
asymptomatic, there is no ongoing damage to surrounding structures, and
with close follow-up and imaging on an as needed basis. There are
currently no guidelines for the treatment of such patients, and their
lack of removal can lead to complications such as cardiac tamponade,
infections, embolisms, or arrhythmias which need to be considered during
your medical decision to not operate on these patients. This patient was
unstable with signs of cardiac strain, severe angina and dyspnea, thus
it was decided the benefits of exploratory sternotomy outweighed the
risks and patient tolerated the procedure well with good outcomes and
removal of the needle in his heart. Thus, it is the authors opinion that
close consideration of risks and benefits of major surgical procedures
should be considered in such patients and they should be treated in a
multi-disciplinary manner with close follow-up, including:
cardiovascular surgery, cardiology, infectious disease, internal
medicine, psychiatry, wound care, and drug abuse rehabilitation as
necessary.
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