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Nailing the Heart
- by Tarek
Marei -
This case presented by Dr. Marei Tarek from Egypt is really spectacular. Read on and find out what happened to a young boy while working in a carpenter's shop in Egypt.

Shot by a nail
A twelve-year-old boy working in a carpenter's shop came to the emergency room twelve hours after being hit in the chest (in the left fourth intercostal space between the mid-clavicular line and the sternal line) by a 10-cm-long nail fired from a nail gun.

Typical nail gun and the nail that was fired.
On arrival at the ER the boy was in stable hemodynamic condition. His blood pressure was 90/60 mmHg, heart rate 100 beats/minute, temperature 36.5 C, and he was fully conscious. The chest examination revealed an entry wound in the bare area of the heart, a musical murmur of severe mitral regurgitation radiating outside the apex of the heart, and crepitations reaching his mid-chest on auscultation in the posterior scapular line.

Assessing the patient
The chest x-ray (lateral and posteroanterior views) revealed a metallic radiopaque object in the intracardiac aspect, which fitted the description of the injurious nail. CT showed a metallic object inside the LV cavity with halos of artifacts around it.

Chest X-Ray – The arrow points to the nail.
The transesophageal echo revealed a metallic object resting on the sub-valvular apparatus of the mitral valve, causing moderate grade III/IV mitral regurgitation due to a flail anterior mitral leaflet, together with a pericardial effusion of 3 mm.

TEE study (four-chamber view) showing the nail passing
through the mitral valve.

TEE study, long-axis view showing the nail in the heart.

TEE study (two-chamber view) showing the
anterior/posterior orientation of the nail.
Not doing well
The patient was admitted to the ICU for monitoring while being prepared for open heart surgery to retrieve the nail and repair the mitral valve. In the ICU his oxygen saturation started to drop to 80%. Oxygen was delivered through nasal prongs, blood units were prepared, and laboratory investigations performed. All laboratory data were satisfactory. His hemoglobin level was 11.7 mg/dl, but we noted a rise in total CK to 250, CK MB to 90, and LDH to 634. Besides, he had leukocytosis (12.7 K/uL).
The patient was admitted to the OR. A radial arterial line was inserted to monitor blood pressure. He was given anesthesia and endotracheal intubation. A central line was inserted into the right internal jugular vein, and a TEE probe into the esophagus. Suction through the endotracheal tube revealed frothy blood, which confirmed the impression of acute pulmonary edema due to the acute onset of mitral regurgitation. TEE showed severe mitral regurgitation; the metallic shadow of the nail moved in and out of the mitral leaflets in conjunction with cardiac contractions.

The operation
The patient was sterilized with betadine, draped, and a median sternotomy was performed. We found a hematoma involving the thymic fat, as well as a hemopericardium (about 150 cc). The end of the nail was spotted passing 3 mm to the left of the LAD artery without injuring the artery and without a hematoma hindering its course. Cannulation of the aorta and both cavities, as well as a cardiopulmonary bypass were performed. The heart was arrested by cold crystalloid cardioplegia delivered through a cannula in the aortic root, and the left atrium was opened. The tip of the nail was seen passing from the LV free wall to the anterior papillary muscle. The latter was torn off, very friable, and there was a flimsy chordal attachment to a torn anterior mitral valve leaflet fixed to the annulus only at the lateral commissure. The nail was withdrawn from the end on the LV free wall.

The nail being extracted from the heart.

The valve was deemed unsuitable for repair because of the flimsy chordae and friable muscle. We decided to replace the valve. A prosthetic valve (size 25) was placed and sutures were performed. The valve was tested. Motion of the leaflets was ensured and the left atrium closed over a venting tube. The entry wound left by the nail on the LV free wall was closed with a prolene 4/0 transverse mattress stitch over two pericardial pieces, without compromising the LAD artery. Debubling was performed and the aortic cross clamp removed. The heart regained its normal sinus rhythm and was separated from the CPB without inotropic support. TEE demonstrated a functioning valve. The patient was transferred to the ICU, where he stayed for two days, and then shifted to the regular ward in good condition.

And the winner is:

Dr. Tarek
Dr. Marei Tarek is a cardiac anesthetist, working at the Faculty of Medicine - Cairo University. In addition he also works at the cardiac surgery unit - Nasser Institute (research and treatment center). He is particularly interested in perioperative management of both surgical and endovascular aortic repairs. 123sonography congratulates Marei to this spectacular case!
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