Foreign bodies in the heart

Definition

A foreign body in the heart is a pathology characterized by the presence of a foreign object in the tissue or cavity of the organ. It is usually a complication of invasive medical manipulations and less often occurs as a result of mechanical trauma. A foreign object can cause perforation of the walls of the organ, the development of arrhythmias, pulmonary embolism, and septic complications. The clinical picture includes dyspnea, stabbing chest pain, and cardiac dysfunction of varying severity. Diagnosis is based on radiography, computed tomography, echocardiography, and angiography results. Treatment is surgical – endovascular removal or surgery with direct access to the heart.

General information

A foreign body of the heart is rarely diagnosed; in medical practice, the prevalence of this condition is less than 0.3% of all cardiac pathologies. More often, adult patients are affected. 87% of objects are iatrogenic, getting into the organ and migrating with blood. The widespread introduction of invasive diagnostics and therapy methods, intravenous infusion of blood, and various solutions into medical practice has increased the frequency of catheter and delivery system breakage or detachment of parts. Circulating through the circulatory system, these elements eventually reach the heart or main vessels. The risk of dangerous complications or fatal outcomes in the presence of this pathology is close to 60%, so surgical removal of the object is indicated for all patients.

Causes

The most common etiologic factor of foreign objects entering the bloodstream is considered to be invasive medical interventions performed not according to standards or using poor-quality equipment and consumables. The main iatrogenic causes are:

• Use of infusion systems. Parts of catheters inserted into the subclavian and femoral veins become foreign bodies. In most cases, this occurs due to mid-level workers’ ignorance or non-compliance with the rules of operation of medical instruments, violation of the installation technique, or removal of systems. 
• Endovascular interventions. Foreign objects are fragments of probes used during angiography, other intracardiac examinations and therapeutic manipulations (angioplasty, stenting), metal leads, artificial valves and their fragments, vessel prostheses, suture elements, and hemostatic material.

Symptoms

The clinical picture has no specific manifestations and consists of cardiologic signs due to the mechanical impact of the object on the muscular wall of the chambers or the conduction system of the heart, as well as complications resulting from this impact. In the early stages or when the size of the foreign body is less than 5 mm, symptoms may be absent, significantly complicating diagnosis. Pathology manifests itself suddenly when damage to cardiac structures can threaten the life of the patient. The main symptom is pain in the sternal region of various character – aching, stabbing, burning, pressing. It is characterized by a significant duration; it is not relieved by nitroglycerin.

The impact of a foreign body on the conducting system can cause brady- or tachycardia, leading to ineffective heartbeats and arrhythmia. Violations of the organ’s function negatively affect the blood supply of tissues. There is weakness, cyanosis, shortness of breath both at rest and with physical exertion, and edema of the lower extremities. When infection with the development of sepsis or septic endocarditis is attached, general hyperthermia, chills, and increased sweating are observed. 

Diagnosis

Due to nonspecific, scarce symptoms in the early stages, detection of the most common non-traumatic etiology object occurs accidentally, usually by cardiologists or therapists during preventive appointments or during examination for other pathology with similar manifestations. The list of diagnostic techniques used in suspicion of a foreign body in the heart area includes:

• Interview, examination. The doctor collects the history of life and disease and clarifies whether there was a history of invasive medical manipulations, especially catheterization of large veins and prosthetic heart valves. He also conducts a general examination for changes in skin color and the development of edema and percussion of the heart area to determine the size, configuration, and position of the organ and the size of the vascular bundle. Doctors perform auscultation at classical points on the chest to assess the valve system and detect abnormal noises.
• X-ray. Radiography of the heart helps to detect X-ray contrast foreign bodies, clarify their localization and size, and establish the number of several objects. According to X-ray data, the size of the heart, large vessels, position, shape, pathological formations, and mobility are determined.
• Computed tomography is a highly accurate method that allows one to obtain a three-dimensional image of the organ, assess the structure and function of the myocardium in motion, and detect low-contrast and non-contrast foreign bodies. CT is the leading study in the diagnosis of complications—pericarditis and thromboembolism of pulmonary arteries—and makes it possible to differentiate from other cardiac pathologies.
• Ventriculography is a technique for clarifying the localization of foreign bodies in the heart chambers. The procedure is performed using a contrast agent immediately before surgical intervention so that the object does not have time to displace or deepen into the muscular layer of the organ.
• Laboratory methods. A decrease in the hemoglobin level and the number of red blood cells indicates the development of anemia. The infectious inflammatory process corresponds to an increased erythrocyte sedimentation rate (ESR), pronounced leukocytosis. In the biochemical analysis of blood, the levels of ALT, AST, myoglobin, and troponins as markers of myocardial damage are essential. Changes in the physiologic ratio of electrolytes are necessary for the differential diagnosis of arrhythmias. An increase in C-reactive protein additionally confirms the presence of inflammation. Coagulogram and platelet count are determined to assess blood viscosity and the possibility of thrombus formation.
• Electrocardiography (ECG) has an auxiliary value. It is used to detect concomitant cardiac pathology, assess the heart rate, nature, and source of rhythm to clarify the type of arrhythmia, position the electrical axis of the heart, and determine the general condition of the myocardium.
• Echocardiography is used to determine morphological and functional changes in the heart, the degree of its blood supply, the state of the valve apparatus, the thickness and clarity of the contours of the muscle walls, pressure in the chambers, blood flow rate, and the detection of increased levels of fluid or blood in the pericardial cavity.

Differential diagnosis of foreign bodies is carried out with diseases that give a similar clinical picture with a leading symptom in the form of pain behind the sternum: angina pectoris, myocardial infarction, dissecting aortic aneurysm, pleurisy, and pneumonia. Pathologies with frequent irradiation of pain in the chest are excluded: hepatic colic, acute pancreatitis, and peptic ulcer.

Treatment of a foreign body in the heart

The choice of surgical tactics depends on several factors: sex and age of the patient, size and structure of the object, as well as associated complications. As auxiliary medications, antiarrhythmic and thrombolytic drugs, such as antibiotics, are used in developing septic processes. The operation is performed in the conditions of cardiac surgery or vascular department. Depending on the patient’s condition, the intervention is carried out urgently with a preparation period of 1-2 days or (in the presence of life-threatening complications). Two main techniques of foreign body removal have been developed:

• Endovascular intervention. The method is the main one in the elimination of pathology. It is a minimally invasive surgical manipulation performed with special instruments by percutaneous access in the subclavian or femoral region under real-time X-ray control. The operation is usually performed under local anesthesia and is easily tolerated by patients. Application of the technique is possible only if the foreign object is radiopaque, not deep into the myocardium, and has dimensions up to 5 mm.
• Open-heart surgery is performed when the endovascular method is impossible. A heart-lung machine is used to manipulate the heart with open access. The newest option is intervention in conditions of non-perfusion hypothermic protection, allowing not only the removal of the foreign body but also conducting revision of the right heart.

All these treatment options are available in more than 550 hospitals worldwide (https://doctor.global/results/diseases/foreign-bodies-in-the-heart). For example, Open-heart intracardiac foreign body removal can be performed in these countries for following approximate prices:

Turkey$18.7 K in 26 clinics

China$23.8 K in 4 clinics

Germany$54.2 K in 26 clinics.

Prognosis and prevention

The prognosis is favorable with timely diagnosis and removal of the foreign body of the heart. The presence of complications, especially infectious complications, advanced age, and concomitant heart pathologies, worsens the possible outcome. Preventive measures on the part of the patient are not developed due to the predominantly iatrogenic etiology of this condition. Preventive examination by a cardiologist or internist every 6-12 months is recommended for early detection of possible cardiac abnormalities. Medical workers should follow the operation, insertion, and removal rules of catheters and other endovascular instruments.