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\begin{document}

\title{Pediatric cardiac tamponade caused by metallic wire penetration into the
heart: A case report and literature review}



\author[1]{Hajime Yamazaki}%
\author[1]{Muneaki Matsubara}%
\author[1]{Hideyuki Kato}%
\author[1]{Kazuo Imagawa}%
\author[1]{Takashi Murakami}%
\author[1]{Bryan Mathis}%
\author[1]{Yuji Hiramatsu}%
\affil[1]{Tsukuba Daigaku Igaku Iryokei}%


\vspace{-1em}



  
  \date{May 07, 2024}


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\selectlanguage{english}
\begin{abstract}
Thin, metallic wires can easily penetrate the gastrointestinal system if
ingested and cause serious cardiac issues in children. We report a
pediatric case of such an object that caused cardiac tamponade after
lodging in the left ventricle. The wire was extracted without
cardiopulmonary bypass and a full recovery was made. Cardiac issues
after ingestion of foreign objects are rare but immediate surgery is
required for resolution.%
\end{abstract}%



\sloppy


\textbf{Introduction}

Foreign body ingestion in children is common but usually causes
gastrointestinal issues and not serious cardiac complications. Here, we
present a pediatric case of cardiac tamponade caused by an ingested
metal wire penetrating into the left ventricle and also review relevant
literature.

\textbf{Case}

A 2-year-old girl was transferred to our hospital with a 5-day history
of epigastric and left-upper-quadrant pain, plus intermittent fever.
Transthoracic echocardiography revealed massive pericardial effusion and
tamponade causing right atrial diastolic compression and tachycardia.
Emergent pericardial drainage was performed, collecting 40ml of
hemorrhagic effusion; however, post-drainage chest radiography
(posteroanterior view) showed a radio-opaque foreign body within the
cardiac silhouette at the left lower border (Figure, A). Computed
tomography of the chest confirmed that a metal wire was lodged in the
posterior wall of the left ventricle through the left diaphragm (Figure,
B, C). Surgical removal was then executed under general anesthesia.
Endoscopic esophagogastroduodenoscopy revealed only a small punctate
area of erythema on the gastric mucosa of the fundus, but no fistula.
Following a median sternotomy, the surface of the heart was revealed to
be covered with reactive fibrous tissues which were carefully released.
The wire appeared to have migrated into the left ventricle through the
diaphragm and was successfully removed from the left ventricle with
forceps but without cardiopulmonary bypass (Figure, D). The wire was
2cm, non-rusted, sharp, and metallic (Figure, E). No bleeding from the
heart was noticed and primary closure of the diaphragmatic fistula was
carried out. The patient made an uneventful recovery and was discharged
in good condition.

\textbf{Discussion}

Foreign body swallowing by children is common, especially in the toddler
and early childhood stages, but cardiac tamponade caused by an ingested
foreign body is rare and usually from chicken or fish bone
fragments.\textsuperscript{1,2} Most metallic foreign bodies pass
spontaneously through the gastrointestinal tract, but sharp, thin
objects are more likely to cause gastrointestinal perforation which has
been reported in 15 to 35\% of cases.\textsuperscript{3} The precise
sequence of events affecting our patient remain unknown; however, it
seems most plausible that the patient accidentally swallowed a broken
steel mesh strainer wire with food which then penetrated into the left
ventricle from the gastric fundus and led to cardiac tamponade. Table 1
shows the demographics and clinical outcomes of five pediatric cases of
ingested metallic foreign bodies with cardiac complications published
since 2001, including the present case\textsuperscript{4,5,6,7}. The age
of the patients ranged from 9 months to 2 years and the perforation site
of the gastrointestinal tract was the esophagus in four previously
reported cases. The cardiac injury site was the pericardium in three of
these cases, plus one case each of right atrium and left ventricle
injury. All reported patients developed cardiac tamponade and
hemodynamic instability that required early surgical intervention, but
all also had good postoperative outcomes. In three of these cases, the
cause was a safety pin, one case was a metallic needle, and, in this
case, a metal wire fragment from kitchenware. In our case, the stomach
was unusually penetrated and the perforation mechanism was thought to be
initial impact, followed by necrosis due to local inflammation and
direct pressure.\textsuperscript{8} To the best of our knowledge, there
are no reports of pediatric cases of cardiac injury caused by accidental
ingestion of metal wires since 2001 and only three adult cases have been
reported\textsuperscript{9,10,11}. Incidentally, in all reported adult
cases, the symptoms and surgical interventions were the same as the
pediatric cases. Although cases of pericardial tamponade secondary to
accidental ingestion of a metallic foreign body are rare, pediatricians
should be aware that delayed diagnosis of both gastrointestinal
perforation and acute hemorrhagic pericardial effusion can have fatal
consequences. It is important to remember that, even if symptoms are
subclinical, prompt examination and rapid treatment are crucial for a
favorable clinical outcome. Our report and the weight of the literature
cases underscore the need for precise diagnosis and surgical
intervention in the pediatric population since accidental ingestion of
metal objects usually manifests as gastrointestinal injury and not
cardiac tamponade with hemodynamic instability. In addition, tamponade
in otherwise healthy children may warrant exploration for wire or other
sharp, thin objects that could penetrate into the pericardium through
the stomach or diaphragm.

\textbf{Acknowledgements} : No funding to declare.

\textbf{Conflict of Interests} : The authors declare that there are no
conflicts of interest.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Jayachandra S, Eslick GD. A systematic review of paediatric foreign
  body ingestion: presentation, complications, and management. Int J
  Pediatr Otorhinolaryngol 2013;77(3):311-7.
\item
  Kim JE, Ryoo SM, Kim YJ, Lee JS, Ahn S, Dong WS, Chang HS, Jeong MR,
  Won YK. Incidence and Clinical Features of Esophageal Perforation
  Caused by Ingested Foreign Body. Korean J Gastroenterol
  2015;66(5):255-60.
\item
  Velitchkov NG, Grigorov GI, Losanoff JE, Kjossev KT. Ingested foreign
  bodies of the gastrointestinal tract: retrospective analysis of 542
  cases. World J Surg 1996;20(8):1001-5.
\item
  Kalayci AG, Baysal K, Uysal S, Sarac A, Bernay F, Gebesoglu F.
  Hemopericardium caused by ingested safety pin. Endoscopy
  2002;34(1):93.
\item
  Krishnamohan P, Perumal M, Kasinathan, Shakir H. A case of suppurative
  pericarditis following open safety pin ingestion in 8 month old
  infant. Indian J Thorac Cardiovasc Surg 2009; 25:38-9.
\item
  Fennessy BG, Rahbar R, Bunker N, Pigula F, Casta A. The needle and the
  damage done: pericardial effusion with tamponade after needle
  ingestion in an infant. J Laryngol Otol 2009;123(12):1396-8.
\item
  Sugunan S, Ajith Krishnan AS, Devakumar VK, Arif AK. Safety-pin
  Induced Hemopericardium and Cardiac Tamponade in an Infant. Indian
  Pediatr 2018;55(6):521-522.
\item
  Sharland MG, McCaughan BC. Perforation of the esophagus by a fish bone
  leading to cardiac tamponade. Ann Thorac Surg 1993;56(4):969-71.
\item
  Fashandi AZ, Boys JA, Yount KW, Buerlein RC, Shami VM, Ailawadi G,
  Walters DM. Isolated hemorrhagic pericardial effusion after foreign
  body ingestion. Ann Thorac Surg 2018;106(3):e141-e143.
\item
  Wei TL, Su W, Jian Z, Chen JH, Qiang L, Xiao YW, Wang FZ. Management
  of acute cardiac taponade afte esophageal perforation by a steel wire.
  Gastroenterol Nurs 2016;39(3):232-4.
\item
  Olivotti L, Succio G, Moshiri S, Nicolino A, Gravano M, Serafini G,
  Chiarella F. Cardiac Tamponade Caused by a Swallowed Metallic Wire. J
  Am Coll Cardiol 2010;56(14): e27.
\end{enumerate}

\textbf{Figure Legends}

Figure 1:

Radiological and operative findings after cardiac tamponade caused by
ingestion of a metallic object (wire). Arrows indicate the wire before
treatment on (A) X-ray and (B \& C) transthoracic echocardiography. (D)
Intra-surgical and (E) post-surgical views of the wire.\selectlanguage{english}
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\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

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\textbf{Table}

Table 1:\selectlanguage{english}
\begin{longtable}[]{@{}lllllllll@{}}
\toprule
References & Year published & Age & Gender & Penetration site &
Localization & Type & Cardiac complication & Outcomes\tabularnewline
\midrule
\endhead
Kalayci et.al. & 2002 & 9 mo & M & Esophagus & Right Atrium & Safety pin
& Cardiac tamponade & Discharged\tabularnewline
Krishnamohan et.al. & 2009 & 8 mo & F & Esophagus & Pericardium & Safety
pin & Cardiac tamponade & Discharged\tabularnewline
Fenessy et.al. & 2009 & 9 mo & M & Esophagus & Pericardium & Metallic
needle & Cardiac tamponade & Discharged\tabularnewline
Sugunan et.al. & 2018 & 10 mo & N/A & Esophagus & Pericardium & Safety
pin & Cardiac tamponade & Discharged\tabularnewline
Present case & 2020 & 2y & F & Stomach & Left ventricle & Metallic wire
& Cardiac tamponade & Discharged\tabularnewline
\bottomrule
\end{longtable}

Reported pediatric cases of ingested metallic foreign bodies with
cardiac complications

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