A Piece of Chainlink Fence in the Heart

A 63-year-old man was mowing the grass along a chainlink fence when he felt a brief stab of intense pain in the middle of his chest. Hours later, precordial pain suddenly arose. On his arrival at our emergency department, a small, bleeding lesion was evident near the right edge of the sternum (Fig. 1).

Fig. 1 Six-month follow-up photograph shows the chest entry point (3rd intercostal space), which is apparently inconsistent with the final position of the penetrating fragment. It is possible that the fragment entered the pericardium, migrated, and penetrated the heart at the apex.

Electrocardiographic (ECG) results were normal, as were cardiac enzyme levels. Chest radiographs revealed a metallic foreign body over the cardiac silhouette (Fig. 2). Transthoracic echocardiography (TTE) showed a hyperechoic fixed mass (1.5 cm) between the interventricular septum and the posterior–inferior left ventricular wall (Fig. 3). Mild pericardial effusion was present. Although very near the mass, the mitral valve apparatus appeared neither damaged nor functionally altered, and no segmental wall-motion abnormalities were seen. On contrast-enhanced computed tomography (CT), the fragment seen was near the apex (Fig. 4A); on volume-rendered 3-dimensional reconstruction, it appeared to be almost completely embedded within the left ventricular wall (Fig. 4B).

Fig. 2 Anteroposterior (A) and lateral (B) chest radiographs show a metallic fragment (arrows) over the cardiac silhouette.

Fig. 3 Transthoracic echocardiography in the apical long-axis view confirms the presence of the foreign body (arrow) in the left ventricle. Real-time motion images are available at texasheart.org/journal

Fig. 4 A) 64-Slice contrast-enhanced computed tomographic scan shows the foreign body near the apex of the heart. B) Volume-rendered 3-dimensional computed tomographic reconstruction reveals the fragment (arrow) in the left ventricle. Ao = aorta; LV = left ventricle; RCA = right coronary artery

Because the patient was clinically and hemodynamically stable, he did not undergo urgent surgery; he was admitted for follow-up. Blood cultures were obtained, and therapy with broad-spectrum antibiotics was started.

At the 6-month follow-up examination, the patient was asymptomatic. The Holter ECG was unremarkable, without any arrhythmic event during the 24-hour recording. The TTE and CT scans were substantially unchanged; the foreign body lay in the same position.

Comment

The penetration of foreign bodies and their retention in the heart can be due to chest trauma or to secondary venous embolization from peripheral injuries. The sequelae chiefly depend on the missile's nature, path of travel, and final position in the heart. As a result, patients can be completely asymptomatic or can present with recurrent fevers and pericardial effusions, thoracic pain, arrhythmias, cardiac tamponade, and infective endocarditis.

The rarity of such events precludes standardized diagnostic and therapeutic protocols; approaches must be tailored in accordance with clinical conditions and surgical risks. Actis Dato and colleagues¹ have advocated the removal of all symptomatic foreign bodies, and of asymptomatic penetrating objects, immediately after injury if there are associated risk factors. Other authors^2–4 have concluded that a penetrating object's location, size, shape, and length of time to diagnosis should all affect the management of asymptomatic patients.

Regarding removal of the foreign body, our patient's situation was borderline. Even though the foreign body was diagnosed early, it was completely asymptomatic. On the other hand, although the fragment was embedded in the myocardium, its nature could not exclude the risk of long-term sequelae.

Computed tomography provided striking anatomic details that enabled initial diagnosis and indicated the position of the metallic object within the ventricle. In our experience, however, TTE was the most useful tool for monitoring the patient's clinical course. It enabled us to rule out possible sequelae, such as left ventricular global and segmental kinetic changes, left-to-right shunt, alterations in mitral valve function, and pericardial effusion, that could have altered the patient's treatment plan. The TTE findings assured us that the patient's clinical course was sufficiently mild to warrant conservative management with close observation.