Multi-organ needle foreign bodies with postoperative left ventricular apical outpouching and suspected mural thrombus: a case report

Cardiac foreign bodies (CFBs) resulting from potential self-insertion behaviors are clinically rare and diagnostically challenging. In patients with cognitive impairment, obtaining a precise etiology can be complex due to an unclear medical history. While surgical removal is the definitive treatment, the dynamic evolution of secondary structural sequelae warrants detailed investigation. This study highlights the diagnostic value of multimodal imaging in monitoring localized myocardial wall abnormalities and the progression of remodeling throughout the clinical course. A 35-year-old male with a childhood history of intellectual disability presented with persistent haematuria and dysuria for 2 weeks. He remained haemodynamically stable without cardiopulmonary symptoms. Contrast-enhanced computed tomography (CT) identified multiple needle-like metallic foreign bodies (FBs) distributed in the pericardium adjacent to the left ventricle (LV), abdominal wall, pelvis, bladder, and penis. Transthoracic echocardiography (TTE) demonstrated a 36-mm linear hyperechoic structure within the LV cavity, moving synchronously with the LV wall. The patient was diagnosed with multiple systemic metallic FBs, including a penetrating intracardiac foreign body, likely originating from self-insertion. The patient underwent an elective median sternotomy for the removal of the cardiac foreign body under intraoperative transesophageal echocardiography (TEE) guidance. A black, corroded metallic needle was successfully extracted from the mid-portion of the anterior LV wall. Other systemic FBs were managed conservatively following multidisciplinary consultation. On postoperative Day 7, follow-up TTE revealed the clinical manifestation of a LV apical outpouching (33 × 21 mm) and a suspected mural thrombus (13 × 7mm). These findings, reflecting the combined impact of chronic myocardial irritation and acute perioperative surgical stress, resulting in a significant reduction in systolic function (LVEF 45%). The patient was discharged on Day 9 and remained clinically stable at the 9-month follow-up, at which point TTE showed a stabilized apical morphology and recovered global function (LVEF 57%). Presumed self insertion of CFBs in patients with cognitive impairment can be clinically occult, requiring a high index of clinical suspicion when a definitive history is difficult to obtain. A multimodal imaging strategy incorporating CT for anatomical localization and echocardiography for functional assessment is essential for effective perioperative management. Furthermore, the clinical manifestation of a left ventricular apical outpouching highlights the vulnerability of injured myocardium and underscores the necessity of a structured long term follow up protocol centered on serial echocardiographic assessment to optimize patient outcomes. Written informed consent was obtained from the patient’s father, who acted as the legally authorized representative due to the patient's intellectual disability and lack of decision-making capacity.