Crossing boundaries: A rare penetrating cardiac injury and survival miracle triggered by a steel nail

Central MessageMisdiagnosis case of a cardiac-penetrating injury due to negative symptoms and no imaging findings.See Commentary on page XXX. Misdiagnosis case of a cardiac-penetrating injury due to negative symptoms and no imaging findings. See Commentary on page XXX. An emergency consultation was requested of the thoracic surgery department due to a lung rupture. During the procedure, a 0.5-cm laceration in the left pericardium was discovered, with visible minor bleeding accompanying the heartbeat. Our department's cardiac surgeons promptly arrived and reviewed the patient's history: a 54-year-old man, injured 36 hours earlier while working in a stooped position, was struck by a steel nail fired from a nail gun in the adjacent room. The steel nail entered through the right margin of the sternum at the second intercostal space (Figure 1), imaging photographs show the steel nail located at the outer edge of the spleen. (Figure 2, A and B).Figure 2A and B, Imaging photographs show the steel nail located at the outer edge of the spleen (arrow). C, Echocardiogram revealed an interventricular septal perforation extending from the A1 segment of the mitral valve to the root of the pulmonary artery, with blood flow of approximately 3 to 4 mm.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Our team performed a pericardiotomy and observed a 0.5-cm rupture on the myocardial surface of the left ventricle, with no active bleeding (Figure 3, A). The damaged myocardium was sutured and repaired. A thorough examination of the left thoracic cavity revealed no penetrating injury entry point for the steel nail. The patient was repositioned to a supine position for an anterior median incision to locate the entry point. Upon thoracotomy, a 1.0-cm laceration near the pulmonary artery and close to the aorta was found and sutured. Echocardiogram revealed an interventricular septal perforation extending from the A1 segment of the mitral valve to the root of the pulmonary artery, with a blood flow of approximately 3 to 4 mm (Figure 2, C and Video 1). No clear damage or regurgitation was observed in the valves. Upon incising the pulmonary artery longitudinally, an endocardial rupture was found and sutured. Near the root of the left semilunar valve of the pulmonary artery, a transverse rupture approximately 0.5 cm in length was found (Figure 3, B) and sutured. The interventricular septal perforation was accessed through the right atrium and interatrial septum due to exposure difficulties and later approached through the aortic incision. A 0.5-cm rupture was found below the left coronary cusp, approximately 2.0 cm away, and was sutured. Subsequently, the right atrium and pulmonary artery incisions were sutured before closing the thorax (Figure 3, C). A transesophageal echocardiogram indicated the disappearance of the color flow across the interventricular septum. The steel nail was removed from the spleen by the hepatobiliary surgery team, along with a splenectomy. The patient recovered smoothly. This is an obvious case of misdiagnosis. The preoperative chest computed tomography scans and the absence of pericardial tamponade symptoms, and neither the emergency nor thoracic surgeons diagnosed a cardiac penetrating injury until it was discovered during surgery. The high-speed, small wound resulted in minimal pericardial bleeding and myocardial self-sealing, making the injury difficult to detect on computed tomography. Echocardiography typically does not miss obvious cardiac injuries, but to assess internal cardiac structural damage such as valve injury or atrial septal perforation, transesophageal echocardiography can be performed. In this case, the thoracic surgeon did not find the trauma entry point through the left thoracotomy field. Considering the patient's history, our surgical approach was changed to a median sternotomy to avoid missing the injury. For penetrating injuries, it is crucial to identify both entry and exit points and the penetration path through the organs to perform the surgery accurately. The organs should be repaired in order of the severity and urgency of the damage to minimize the risk associated with changing the patient's position during surgery, as occurred in this case. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3OWM3Mzc2NDljNGI0NGI1OGFkZjFiMDQ1MDkxOGFkOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzIzNTk1NzcxfQ.WW_LVm9ZhQY0h9S0sOZT4Rs9LvKuo1dUi5D750dyphKq_R7vwUr-gCsAgC7U-qYhEuB06YOONkDQFgXe_f4wZO1DlWkWmOINqARdWss837ywdHo65YZKB4uJ7GHKaX7Kjz56MbAT8pzRI5QFhD7wzo5rzrFVjguX4LYh5g1gEq6a0dGynisdzmfH1YiwqD4P5EH8b-_dfs-2SyJIdzXettT0oJJ8XigzX1soIvJYVMeRf2y4Ryp4eCpzWhcabQUayJ2Joef37uzsGI3f6tRxkJ-P5cBQS3Y5R9JXOHWPEj5Tn75I9wCVqNzed0ejXeFquNTxZk0s96dfzn3CQ547Gw Download .mp4 (0.48 MB) Help with .mp4 files Video 1Transesophageal echocardiogram of the left ventricular long-axis plane shows a septal perforation extending from the A1 segment of the mitral valve to the right ventricle, with a blood flow of about 3 to 4 mm. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00263-3/fulltext. Download .jpg (.27 MB) Help with files Video 1Transesophageal echocardiogram of the left ventricular long-axis plane shows a septal perforation extending from the A1 segment of the mitral valve to the right ventricle, with a blood flow of about 3 to 4 mm. Video available at: https://www.jtcvs.org/article/S2666-2507(24)00263-3/fulltext.