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.