Management of Accidental and Iatrogenic Foreign Body Injuries to Heart- Case Series

Lost and found: trends in litigation and compensation related to retained surgical foreign bodies

Introduction

Retained surgical foreign bodies are supplies and devices unintentionally left at the surgical site. They are generally considered never events, albeit even full compliance with procedures can only minimize the risk of their occurrence. As never events, affected patients often allege gross negligence, and hospitals are often forced to compensate for the damages. Despite the fact that the physical consequences of the retention are usually mild and temporary, and thus the compensation paid may be hypothesized to be correspondently low, clear data on the medico-legal outcomes of these claims-both extrajudicial and judicial-and the average compensation have not yet been described.

Materials and methods

This paper presents a retrospective study on the related claims received between 1 January 2010 and 30 May 2024 by a large university hospital in Florence (Italy). The study aimed to deduce their incidence and mean costs, as well as the risk of medical malpractice claims leading to criminal complaints.

Results

We identified 27 eligible cases, with a mean compensation of €20,695.49. During the same period, the claims unrelated to retained foreign bodies, used as controls, had a mean compensation of €67,542.26. When considering only non-fatal events, criminal lawsuits were present in 12% of the cases compared to 6% in the control group, which fell within the same compensation range. The majority of the cases (63%) were directly managed by the hospital, although this was a lower percentage compared to the control cases (76%).

Discussion

In conclusion, even if the economic dimension of claims related to retained surgical foreign bodies is relatively contained, they are associated with a 2-fold risk of criminal lawsuits for doctors. In addition, patients are less confident about out-of-court settlements provided directly by hospital committees compared to judicial court trials. This indicates that patients perceive a retained surgical foreign body (RSFB) as a never event, which requires less justification compared to other wrongful medical care incidents. This perception is likely driven more by a breach of trust in doctors and hospitals than by the severity of consequences, which are typically mild or limited to temporary impairment.

Multiple Retained Needles in the Chest and Abdomen Due to Self-Injury: A Case Report

Retained needles are rarely observed in multiple locations. Furthermore, although case reports on retained needles have been published, there are no standardized guidelines for managing retained needles. A 42-year-old man with schizophrenia was referred to our hospital for intensive care because of a pericardial effusion and 12 needles from needle pricks being retained in both his chest and abdomen. First, he underwent emergency pericardial drainage. Thereafter, he underwent surgeries to remove a needle from the pericardium on day 7, abdominal needles on day 14, and intrapulmonary needles on day 30. He was transferred to a psychiatric ward on day 36 after it was confirmed that no needles remained in the body. We report a case of multiple needles being retained in multiple locations due to self-injury caused by schizophrenia. Future guidelines are needed to help clinicians manage patients with retained needles.

A fragmented segment of a central venous catheter caused delayed ventricular fibrillation: a case report

BACKGROUND

Central venous port systems may be safely used for chemotherapy of patients with cancer, but several complications may occur associated with their use.

CASE PRESENTATION

An 83-year-old man with heat stroke was transferred to our emergency department, where he was treated and became able to eat on the same day. He had been fit and healthy, except for colorectomy and chemotherapy using a central venous access port placed in the right upper jugular vein 8 years ago. The next day, he suddenly had ventricular fibrillation. Cardiopulmonary resuscitation was successful. Emergency coronary angiography showed a catheter-like foreign body in the coronary sinus. Physicians failed to remove the foreign body using catheter therapy, and ventricular fibrillation occurred repeatedly. After induction of general anesthesia, the fractured catheter was removed surgically. Postoperative course was uneventful.

CONCLUSIONS

A fragmented segment of a catheter may suddenly cause ventricular fibrillation years later.

Needle in the heart: a rare case of cardiac tamponade caused by a migrated foreign body and mimicking ST segment elevation myocardial infarction

BACKGROUND

Pericardial tamponade is a serious condition which may eventually lead to severe haemodynamic disturbances and cardiac arrest. It is most often caused by the accumulation of fluid inside the pericardium, as a result of different aetiological factors such as pericarditis, neoplastic diseases, lymphatic dysfunctions, or idiopathic pericardial disease. Pericardial tamponade can develop after cardiac surgical procedures or as a complication of myocardial infarction. Collection of blood inside the pericardial sack can be the result of pericardial or cardiac trauma. It is exceedingly rare for the injury to be caused by a migrating foreign body. Although a typical picture of pericardial tamponade has been previously described, the disorder may clinically resemble an acute myocardial infarction.

CASE PRESENTATION

We report the case of a 58-year-old female patient complaining of new onset thoracic pain and shortness of breath. Electrocardiographic examination results were suggestive of an acute inferior myocardial infarction. However, echocardiography revealed significant pericardial tamponade. The cause was found to be a needle which remained inside the pelvis following a previous cesarean delivery, which the patient had undergone 18 years prior. In emergency setting, the needle was removed and the pericardial tamponade was resolved. Due to the prompt and efficient management, the patient had an uneventful postoperative recovery and presented no recurrence at the follow-up examinations.

CONCLUSIONS

The migration of foreign bodies through tissues is exceedingly rare. If present, it may cause life-threatening complications. Since the aetiology of pericardial tamponade is vast, a thorough assessment is highly important. Therefore, echocardiography is the imaging modality of choice. We wish to highlight the possibility of migrating foreign bodies as probable cause for pericardial tamponade, as well as the importance of echocardiographic methods in the fast-track evaluation of such critical conditions.

A case report of an unusual left atrial mass

Background

Cardiac foreign bodies (FBs) are rare findings that may present as cardiac masses initially. Here, we present an exceptional and rare case of a hypodermic needle FB that transmigrated to the left atrium and presented as a left atrial mass.

Case summary

A 28-year-old woman with multiple psychiatric disorders including intentional FB ingestion and self-inflicting injuries presented to the emergency room with abdominal pain, nausea, vomiting, diarrhoea, and chest pain that radiated to the left arm and face for 2 weeks. An echocardiogram was performed revealing a left atrial mass concerning for myxoma. During the surgical removal of the mass, a hypodermic needle was found attached to the roof of the left atrium surrounded by thrombotic and fibrotic tissue, which was confirmed by pathology.

Discussion

Cardiac FBs are caused generally by penetrating wounds from direct trauma. Fewer cases have been reported regarding cardiac FB caused by ingestion from migration of the object to the heart. Signs and symptoms for cardiac FB may mimic those of cardiac masses. Cardiac FBs often require surgical intervention to avoid complications.

Uneventful survival of a rural child after penetrating cardiac injury by a thorn: a case report

Background

Paediatric penetrating cardiac injury is extremely rare, precluding published management guidelines, therefore warranting a case-by-case approach with learning points gleaned from each case.

Case summary

A 7-year-old boy presented to a rural hospital with a stab wound to the chest by a Withaak (Vachellia tortilis) thorn. The patient was haemodynamically stable on presentation, but a 2 cm subcutaneous, pulsatile mass was present at the cardiac apex. Echocardiography revealed a foreign body penetrating from the apex into the heart, with evidence for a fistula between a cardiac chamber and the pulsatile mass. Angiography confirmed the existence of the fistula between the right ventricle (RV) and the pulsatile mass. A controlled extraction under general anaesthaesia via median sternotomy was performed in-theatre, with blood products and cardiac bypass on standby. The patient recovered without complications and was discharged after 4 days.

Discussion

Our case illustrates the limitations of echocardiography in identifying the precise anatomical definition of penetrating cardiac injuries. Angiography is therefore indicated in such cases. The injury to the RV and the haemostatic effects of the in situ thorn were favourable prognostic factors. We believe that the mortality risk reduction of extraction under full control warrants the minor morbidity of a median sternotomy.

An Unusual Presentation of a Cardiac Foreign Body in a Pediatric Patient

Cardiac foreign bodies (FBs) are rare. Their etiology can be attributed to penetrating injuries although they are also often found incidentally. The approach for removal of these FBs is variable and patient dependent. Although there is debate regarding indications for removal, there is a general consensus that symptomatic FBs presenting acutely, as well as asymptomatic FBs posing a greater risk of complication to the patient, should be removed. We present the case of a 14-year-old patient with a cardiac FB and a step-wise approach for removal.

Inadvertent Traumatic Fracture of Central Venous Catheter during Procurement, Transmitted Through Solid Organ Transplant

Central venous catheters play a pivotal role in the perioperative support of critically ill patients. They are used for administration of fluids, vasopressors, blood products, and various medications; however, their use may be associated with serious complications, such as catheter fracture and embolization. While most data on catheter fracture embolization consist of isolated case reports, only a few studies have examined patients with central venous catheter embolism. We report a traumatic inadvertent transection of central venous catheter that migrated through a donor transplanted liver and was found to be lodged in the recipient's right ventricle. The catheter was retrieved under fluoroscopy using a trilobed snare device.