Mechanical Aortic Valve Replacement Following Self-Inflicted Cardiac Needle Penetration in a Patient with Recurrent Self-Harm: A Case Report with Fatal Long-Term Outcome

Background and Clinical Significance: We report an exceptionally rare case of mechanical aortic valve replacement necessitated by self-inflicted needle penetration with aortic valve and left ventricular involvement in a patient with recurrent self-harm behavior. Case Presentation: A 24-year-old female with post-traumatic stress disorder and emotionally unstable personality disorder, borderline type, presented with dyspnea two weeks after self-inserting multiple needles into her thorax. Computed tomography revealed a needle lodged in the aortic root and an intramyocardial needle with hemorrhagic pericardial effusion. Emergency sternotomy revealed inflammatory destruction of the right coronary aortic cusp with complete perforation. Following failed reconstruction attempts, mechanical aortic valve replacement was performed. The patient survived the immediate postoperative period but demonstrated recurrent non-adherence to oral anticoagulation, including multiple episodes of over- and under-anticoagulation. More than six years after surgery, she presented with cardiogenic shock due to prosthetic valve thrombosis after discontinuing warfarin for two weeks. Despite venoarterial ECMO and fibrinolytic therapy, she died from refractory left ventricular failure. Conclusions: This case highlights critical challenges in managing patients with severe psychiatric disorders requiring mechanical valve prostheses and suggests that bioprosthetic valves may warrant careful consideration in patients with major concerns regarding long-term anticoagulation adherence.