Case report:
A 28-year-old male presented with acute pressure-like chest pain and
dyspnea that began
suddenly the night prior to arrival after using crystal methamphetamine,
with no aggravating
or alleviating factors and no other associated symptoms. On physical
examination patient was
afebrile 36.5°C, tachycardic ranging 115-125, with a respiratory rate
18-30, and blood
pressure ranging wildly from 131/117 at highest to below 90/60. Patient
was anxious, in acute
distress, diaphoretic with distant heart sounds, and rapid faint distal
pulses.The patient had known history of metabolic syndrome, untreated
hepatitis C, and intravenous drug abuse with methamphetamines and
heroin. He had two needles break off into his right arm 2 years prior to
this event. He was taking suboxone for drug abuse. He had no prior
surgeries or other known medical conditions.
Initial troponin was normal (<0.012 ng/mL), Initial CXR was
unrevealing. EKG in ED demonstrated subtle ST elevations in the
inferolateral leads which led to a concern for STEMI, so a right and
left coronary angiogram and left ventriculogram were performed with
multiple views taken. See figures1-5. These demonstrated normal
coronary anatomy with mild atherosclerosis, an EF of 55%, and mild
inferior hypokinesis. It appeared as if there was a foreign body inside
the heart and so a stat CT scan was ordered to rule this out, and an
echocardiogram was obtained to rule out tamponade. See figures
6-8. CT scan confirmed presence of needle in the right ventricle, and
echocardiogram confirmed presence of tamponade with partial right
ventricle diastolic collapse.
Given sudden hypotension and tachycardia, the patient was given rapid
intravenous fluids to temporize blood pressure while being rushed to the
operating room where an emergent median sternotomy was performed. During
this procedure 500 ml of fluid was drained from within the pericardial
sac. Upon exploration of the mediastinum a needle was found in the
fibrous scarring of the right ventricular epicardium (Figure
9 ). The needle had burrowed through the right ventricular cavity to the
outer surface of the right ventricular epicardium. A second needle was
not found; thus, the pericardial sac was copiously irrigated, three
chest tubes were placed, and the sternum was closed. The patient was
then placed on cefuroxime for 48 hours for concern for possible
endocarditis, but given normal white blood cell count, lac of fever,
improving chest pain, and negative blood cultures at 48 hours,
infectious disease consult deemed it ok to stop antibiotics. A CT of the
RUE and chest were obtained to confirm that there was not a second
needle in the heart. RUE CT demonstrated a needle within the antecubital
fossa that was stable and not damaging nearby structures, given this it
was decided to not remove the needle and observe as outpatient. The
three chest tubes drained an additional 500 ml of fluid before being
removed and patient was discharged with close follow up on
post-operative day 4 after an uneventful post-operative course. Follow
up chest x-ray at one week and one month did not show any significant
acute findings. Patient followed up in surgery clinic one month after
discharge and did not have any acute concerns.