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Successful removal of migrated acupuncture needles in a patient with cardiac tamponade by means of intraoperative transesophageal echocardiographic assistance
Address for reprints: Jae-Joong Kim, MD, PhD, Division of Cardiology, Department of Internal Medicine, University of Ulsan, College of Medicine, Asan Medical Center, 388-1, Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
Cardiac tamponade is a potentially life-threatening condition that can cause death if not diagnosed and treated promptly. Here we describe a case of cardiac tamponade caused by penetration of the right ventricular free wall by migrated acupuncture needles. The needles were detected and successfully removed with intraoperative transesophageal echocardiographic assistance.
Clinical Summary
A 49-year-old woman was admitted to our hospital after having chest pain and was then hospitalized 2 hours later after syncope. She had a history of recurrent episodes of pulmonary thromboembolism that arose from deep vein thrombosis. A Bird’s Nest filter (Cook Co, Leechburg, Pa) was implanted in her inferior vena cava for the prevention of embolism about 6 years ago. Four weeks before admission, she felt bilateral shoulder pain and subsequently received acupuncture treatments to relieve the pain. She was treated with acupuncture on her shoulder and upper back 2 hours before symptom onset. Her blood pressure was 70/48 mm Hg in the emergency department, where a transthoracic echocardiogram showed a large amount of pericardial effusion with tamponade features. After detecting fine and linear foreign material sized approximately 5 cm penetrating the interventricular septum and right ventricular wall (Figure 1,
A), a pericardiocentesis was immediately performed. After draining about 600 mL of fresh blood from the pericardial cavity, blood pressure was normalized. The foreign material was seen in the fluoroscopic and computed tomographic examinations (Figure 1, B and C); however, there was no evidence of migration of Bird’s Nest filter (Cook Inc, Bloomington, Ind).
Figure 1A, Transthoracic 4-chamber view. A 5-cm, linear, needle-shaped mass is identified penetrating the ventricular septum and right ventricular wall (arrow) and surrounding large amount of pericardial effusion with tamponade features (arrowhead). B, The computed tomogram revealed needle-shaped masses in the interventricular septum and the distal part of the left bronchial artery. C, The needle was seen in the interventricular septum in the enhanced tomographic scan. PE, Pericardial effusion; RV, right ventricle; LV, left ventricle.
The emergency cardiac operation was done to remove the foreign bodies with intraoperative transesophageal echocardiographic guidance (Sonos 2000; Hewlett-Packard Co, Andover, Mass) with a multiplane probe. The transesophageal echocardiogram showed a needle-shaped mass crossing the interventricular septum. After the pericardiectomy, the needle-shaped foreign material was seen penetrating the right ventricular wall and was removed successfully. Despite of the removal, an intraoperative transesophageal echocardiography revealed another needle-shaped foreign body crossing from the interventricular septum to the left ventricular cavity (Figure 2, A). After a cardiopulmonary bypass, her left atrium was opened, and the foreign body was successfully removed. The removed foreign bodies were thin, needle-shaped materials (Figure 2, B).
Figure 2A, Intraoperative transesophageal echocardiograms: modified transgastric view demonstrating another needle-shaped mass penetrating the interventricular septum after removal of a needle-shaped mass penetrating the right ventricular wall. B, Removed masses were proved to be acupuncture needles. RV, Right ventricle; LV, left ventricle.
The materials were proved to be acupuncture needles after a comprehensive analysis from the Department of Acupuncture, College of Oriental Medicine, Kyung Hee University and the Department of Biomedical Engineering, Inje University. She was discharged after the operation without any complication.
Discussion
Acupuncture is an ancient Chinese treatment used to relieve pain from different causes.
Cases with cardiac tamponade usually experience direct injury of the coronary artery or pericardium by the acupuncture needle. However, in this case cardiac tamponade occurred as a result of the migrated acupuncture needles.
Reported cases of needle embolisms can be found, and previously, we submitted a case with cardiac tamponade caused by needle-shaped acrylic bone cement after a percutaneous vertebroplasty. Fortunately, cases with cardiac tamponade caused by migratory intravascular needles are extremely uncommon.
Transesophageal echocardiography is useful in cardiopulmonary resuscitation, management of hemodynamic instability after cardiovascular operation,
Transesophageal echocardiography monitoring in the intensive care department the management of hemodynamic instability secondary to thoracic tamponade after single lung transplantation.
In our case the second needle could be successfully removed with the assistance of an intraoperative transesophageal echocardiography. An intraoperative transesophageal echocardiographic examination can be useful in the diagnosis, characterization, localization, and guidance of the removal of foreign bodies.
We appreciate Tae Seon Baek, MD (Department of Oriental Medicine, Kyung Hee University College of Oriental Medicine), for his assistance in the analysis of the foreign bodies.
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