Case presentation
Institutional review board approval for reporting this case and the need for informed consent were waived as per the institution regulation An otherwise healthy, 32-year-old male was admitted electively to our department with chest pain and shortness of breath on moderate exertion that was progressing with time over one year. His initial chest X-Ray showed a foreign body at the apex of the heart. On inquiry, the patient gave a history of Nail Gun Injury to the chest four years ago, which caused a very small wound in the left side of the chest that had minimal bleeding and some pain for two days that was relieved by pain killers. He did not seek any medical advice afterward since the pain resolved and he continued to be asymptomatic until one year ago when he started to have chest pain and shortness of breath on severe exertion that progressed over the year to occur with moderate exertion. Echocardiogram showed preserved left ventricular function with a hyperechoic foreign body at the posterior basal part of the left ventricle (Figure 1). All valves had normal structure and function. Computerized Tomography (CT) of the chest with contrast was performed to better understand the exact position of the foreign body and its relation to the surrounding structures. The chest CT showed a long narrow white shadow (measuring 5 cm) penetration the medial part of the left lung and the posterior basal part of the left ventricle with a fibrous band surrounding the foreign body (Figure 2). Coronary angiography was performed to rule out any coronary injury given the patient presentation with unstable angina. The coronary angiogram revealed a fistula between the tip of posterolateral branch of the right coronary artery and the left lower lobe posterior basal segmental branch of the left pulmonary artery (Figure 3).
The decision was made to take the patient to the OR for removal of the foreign body and ligation of the coronary pulmonary fistula. After median sternotomy, the pericardium was then opened, which interestingly showed no bleeding or effusion. The heart was left for examination and showed a thick fibrous band that 2 cm wide connecting the posterior basal part of the left ventricle and the posterior pericardium, Heparin was administered and cardiopulmonary bypass (CPB) was established using ascending aortic cannulation and two-stage venous cannulation. The heart was drained and the operation was performed on a beating heart. The fibrous band was resected circumferentially off the posterior pericardium and revealed the nail that was protruding from the medial part of the left lung. The nail (Figure 4) was pulled off the lung tissues and then the other end was pulled off the left ventricular wall with difficulty. The two ends of the fibrous band on both sides (the heart and the posterior pericardium and left pleura) that are containing the bridging collaterals of the fistula were ligated using 2 U-shaped 3-0 prolene mattress sutures supported with pledgets (Figure 5). The patient had non-eventful postoperative course and was discharged home after 4 days in stable condition.