Direct Nail Injury to the Heart Without Functional or Hemodynamic Compromise
A 14-year-old girl was admitted to the emergency room (ER) because of blast injury. On arrival, her blood pressure was 100/70 mm Hg, with a heart rate of 140 bpm. She had superficial facial burns and multiple lacerations on different parts of her body. There was an entry wound in the right posterior axillary line at the level of the eighth intercostal space. On auscultation, she had normal heart sounds and slightly diminished breath sounds in the right lung. A chest radiograph showed a right hydropneumothorax and a nail sitting horizontally within the cardiac silhouette (Figure 1).
A right chest tube was inserted. Computerized tomographic (CT) scan of the chest (Figure 2) showed a 4-cm long nail in the heart. Transesophageal echocardiography (Figure 3) revealed a nail within the right ventricle; cardiac function was normal. At emergency sternotomy, a small hole was found at the right lower aspect of the pericardium. No blood was seen in the pericardium. There was contusion of the right atrial wall above the inferior vena cava. The patient was placed on cardiopulmonary bypass (CPB) using aortic and bi-caval cannulation. After aortic cross-clamp arrested the heart, the right atrium was opened and the nail was identified in the right ventricular muscular septum of the tricuspid valve (Figure 4). It was removed from the septum and a single stitch with pericardial pledges was placed to ensure septal integrity. The chordae appeared to have suffered heat damage, probably caused by the nail on entry. A transesophageal echocardiogram at the end of the operation revealed no ventricular septal defect, minimal tricuspid regurgitation, and normal right ventricular function. The patient’s postoperative course was uneventful.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.