| DISCUSSION

Suicide represents a critical and frequently overlooked public health issue, with yearly fatalities surpassing those resulting from interpersonal violence and wars combined. Among elderly adults, depression serves as a prominent contributing element in suicide attempts. Oftentimes, societal stigmas linked to mental illness and suicide impede precise reporting, rendering the actual extent of the predicament challenging to gauge accurately (4). Despite being infrequent, self-inflicted harm ensuing from the insertion of sewing needles into the thoracic region holds severe and potentially lethal ramifications (5,6). Based on the 1969 account by Schechter and Gilbert, nearly 56% of recorded injuries triggered by pins and needles in the heart and primary blood vessels stemmed accidentally. Conversely, around 33% of these injuries were attributable to self-harm (2). Between 1967 and 2013, merely 40 instances of sewing needle impalement of the heart were documented. Ninety percent of these cases transpired in patients afflicted with major psychiatric disorders. Only three cases involved incidental needle penetration devoid of any connection to psychiatric pathology (7). Self-destructive actions might manifest in individuals grappling with specific medical conditions, inclusive of Lesch-Nyhan, de Lange, and Gilles de la Tourette’s syndromes, alongside those with cognitive impairments. These behaviors can similarly correlate with diverse psychiatric conditions, such as personality disorders, dissociative disorder, schizophrenia, major depressive episodes, mania, and gender dysphoria (8). Our subject possibly suffers from depression and ADHD. Trauma induced by projectiles, blades, or hooks constitutes a distinct classification of cardiac trauma (2,9). Foreign entities breaching the heart are comparatively unusual, yet they generally entail bullets, acupuncture needles, K-wire shards, fragment grenades, venous catheters, or occasionally sewing needles (10,11). Notably, our patient presented to our facility following penetrating trauma instigated by a syringe needle and a suicide attempt. Across numerous records detailing individuals embedding needles into their hearts, a substantial proportion of them ingested illicit substances or alcohol just beforehand, arguably influencing their judgment and propensity toward risky conduct (12). Nevertheless, in our scenario, there existed no record of substance usage. Individuals harboring a sewing needle within their heart commonly experience difficulty breathing and chest discomfort. Still, some may remain asymptomatic (13). Such symptoms emerged in our patient too. Total suicide via needle is exceptional (2). In our situation, it didn’t culminate in demise either. People engaging in such activities ordinarily visit hospital emergency departments and survive, albeit lacking immediate diagnosis and treatment could result in mortality owing to self-inflicted injuries to the heart. Thus, expedient medical assistance remains vital in averting fatalities arising from self-inflicted cardiovascular injuries (12). Timely rescue spared our patient from expiring, given rapid transfer, identification, and management. Penetrating heart injuries mostly materialize on the proper ventricle wall, pursued by the remaining sections - left ventricle wall, right atrium, and finally left atrium. Ensuing clinical implications and results rely on multiple elements, incorporating the nature of the instrument utilized, wound position, concurrent pericardium trauma, and the status of the adjacent lung. Pericardial tamponade stands among the most frequent causes of fatality concerning piercing cardiac wounds (2). Leaving a needle embedded in the heart untended yields several hazardous repercussions: First, given its sharpness, the needle can rapidly navigate tissue layers, engendering hemothorax, cardiac tamponade, and pneumothorax. Second, should the needle cease moving, blood clots may still develop, increasing risks for additional complications, namely embolism. Third, though exceptionally rare, needles lodged in the heart can trigger valve damage (valvular insufficiency) or bacterial endocarditis; And forth, Prompt medical attendance becomes indispensable should a needle enter the ventricular septum (1,14). Remarkably, in our patient, trauma transpired precisely at the most typical locale (the free wall of the right ventricle), and the pleura sustained collateral damage. Quick identification and operation ensued ahead of possible tamponade or demise risks. Extracting the needle emerges as imperative, primarily due to its capacity to induce severe complications if retained. Surgeons prefer extracting it via open-heart surgery coupled with a heart-lung apparatus. Three reports exist regarding serendipitously embedded sewing needles managed operatively requiring CPB (7). If the needle fails to anchor itself within heart muscle fibers or cannot be palpated externally, open-heart surgery accompanied by CPB proves necessary for safe retrieval (10). However, in our case, the needle’s tip protruded visibly on the heart surface. Since the needle measured significantly long and became deeply embedded in the right ventricular wall, manual extraction succeeded post-precise localization utilizing Trans Thoracic Echocardiography (TTE). Prior to performing the procedure, physicians utilize imaging modalities like echocardiography to obtain a thorough understanding of the needle’s position, dimension, and mobility within the heart. Echocardiography ranks as the favored technique due to its remarkable precision, avoiding ionizing radiation exposure. Considering its ability to generate detailed images illustrating heart structures and functions, surgeons leverage this information to optimize preoperative planning strategies for effective needle retrieval. Accuracy assumes utmost importance during echocardiographic assessment, as minor mistakes carry grave implications for the patient’s safety. Both TTE and TEE (Trans Esophageal Echocardiography) serve as viable options for locating foreign items within the heart (15,16). In this instance, TTE was selected based on convenience and reduced invasiveness compared to TEE.