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Communications to the Editor |

Cardiac Tamponade Following Acupuncture FREE TO VIEW

Tsung O. Cheng, MD, FCCP
Author and Funding Information

Affiliations: George Washington University Medical Center Washington, DC,  General Hospital Wels Wels, Austria

Correspondence to: Tsung O. Cheng, MD, FCCP, Professor of Medicine, Division of Cardiology, Department of Medicine, The George Washington University Medical Center, 2150 Pennsylvania Ave., NW, Washington, DC 20037



Chest. 2000;118(6):1836-1837. doi:10.1378/chest.118.6.1836-a
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To the Editor:

I read with interest the recent case report of cardiac tamponade following acupuncture by Kirchgatterer et al (May 2000).1 According to these authors, only three other similar case reports were found in the literature.24 I wish to call their attention to another three case reports that preceded the three they cited.

The first case report of cardiac tamponade following acupuncture was by Schiff5 from Miami, FL, and was published in 1965. The subject, an 82-year-old Hungarian emigré, was found dead in her home by a relative. According to her next-of-kin, she was known to have practiced acupuncture for chronic angina. At autopsy, the acupuncture needle point was found to have penetrated the anterior surface of the heart for a distance of 1/8 inch, producing a wide laceration of the distal branches of the left anterior descending coronary artery close to the apex. The pericardial cavity was filled with 250 mL of partially clotted blood. The anterior pericardial surface showed petechial hemorrhages above the site of the needle puncture. There were also small focal areas of fibrosis lateral to the hemorrhages suggestive of recent and past needle punctures.

The second case was reported by Nieda et al6 from Japan, and was published in 1973. A 55-year-old man was transferred from another hospital because of precordial pain and clinical state of shock. He received acupuncture treatment for his long-standing epigastric pain 11 h before his arrival at the hospital. Fluoroscopy showed the acupuncture needle, about 4 cm in length, to lie in the parasternal region of the left hemithorax. At emergency thoracotomy, the needle was found to have penetrated the pericardium and was removed successfully. Approximately 600 mL of dark blood was aspirated from the pericardial cavity, and scratch wounds in the right ventricular outflow tract due to the acupuncture needle were found and repaired. Postoperatively, the patient recovered uneventfully.

The third case was reported by Dwivedi et al7 from India and was published in 1991. A 40-year-old hebephrenic-schizophrenic, accidentally detected as having a pericardial friction rub, was admitted with a 3-day history of chest pain 4 months previously. Clinical examination revealed a pericardial rub, and ECG showed generalized T-wave changes. Echocardiography showed anterior and posterior pericardial effusion with a highly echo-dense needle-like object traversing the anterior pericardium, right ventricular free wall, and interventricular septum, with its free end lying in the left ventricular cavity. The patient had inserted needles in parts of his body wherever and whenever the pain occurred, and an acupuncture needle had been inserted in the above-mentioned episodes of chest pain. At operation, the needle was found to lie between the distal left anterior descending coronary artery and a prominent right ventricular branch of the right coronary artery and had traversed the right ventricular free wall near the septum. One end of the needle was in the pericardial cavity, and the other was in the left ventricular cavity with organized thrombus covering the length of the needle. The postoperative course was uncomplicated, and echocardiography performed after 2 months showed no evidence of pericardial effusion. Although the authors did not mention whether there was cardiac tamponade, it was obvious that the pericardial effusion was massive enough to warrant surgical intervention.

Acupuncture is an ancient Chinese treatment that has proven effective in relieving pain from different causes.8 Although it is a relatively innocuous procedure widely practiced worldwide, it is not without risks. Its cardiac complications, besides pericardial effusion and cardiac tamponade, which proved fatal in two cases3,5 of the seven reported cases,17 also include infective endocarditis.910 Thus, it is important to emphasize these risks, particularly in view of the resurgence of enthusiasm expressed on the beneficial effect of acupuncture in patients with angina pectoris,1112 drug addiction and AIDS.1314 The delayed onset of pericardial effusion many months to years after the initial needling episodes2,7 makes the diagnosis even more difficult. Finally, cardiac tamponade following acupuncture can occur even in the best hands; the patient with delayed cardiac tamponade reported by Hasegawa et al2 was himself a professional acupuncture therapist who on occasion treated himself.

References

Kirchgatterer, A, Schwarz, CD, Höller, E, et al (2000) Cardiac tamponade following acupuncture.Chest117,1510-1511. [CrossRef]
 
Hasegawa, J, Noguchi, N, Yamasaki, J, et al Delayed cardiac tamponade and hemothorax induced by an acupuncture needle.Cardiology1991;78,58-63. [CrossRef]
 
Halvorsen, TB, Anda, SS, Naess, AB, et al Fatal cardiac tamponade after acupuncture through congenital sternal foramen [letter]. Lancet. 1995;;345 ,.:1175. [CrossRef]
 
Kataoka, H Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle.J Thorac Cardiovasc Surg1997;114,674-676. [CrossRef]
 
Schiff, AF A fatality due to acupuncture.Med Times1965;93,630-631
 
Nieda, S, Abe, T, Kuribayashi, R, et al Cardiac trauma as complication of acupuncture treatment: a case report of cardiac tamponade resulting from a broken acupuncture needle.Jpn J Thorac Surg1973;26,881-883
 
Dwivedi, SK, Gupta, LC, Narain, VS Self-inserted needle in the heart: localization by cross-sectional echocardiography.Eur Heart J1991;12,286-287
 
Cheng, TO Pericardial effusion from self-inserted needle in the heart [letter]. Eur Heart J. 1991;;12 ,.:958
 
Cheng, TO Acupuncture needles as a cause of bacterial endocarditis [letter]. BMJ. 1983;;287 ,.:689
 
Cheng, TO Subacute bacterial endocarditis following ear acupuncture [letter]. Int J Cardiol. 1985;;8 ,.:97. [CrossRef]
 
Cheng, TO Acupuncture treatment for angina [letter]. Cardiology. 1998;;90 ,.:152. [CrossRef]
 
Cheng, TO Acupuncture for relief of angina.Circulation1998;98,2357-2358. [CrossRef]
 
Cheng, TO Acupuncture risk [letter]. Med Tribune. 1988;;29(34) ,.:16
 
Cheng, TO Acupuncture and acquired immunodeficiency syndrome [letter]. Am J Med. 1989;;87 ,.:489
 
To the Editor:

We thank Dr. Cheng for his interesting remarks. We agree with Dr. Cheng that acupuncture as an ancient Chinese treatment has proven effective and is practiced worldwide. In our opinion, it is very important to bear in mind its rare cardiac complications.

We have not cited the articles of Schiff1and Niedo et al,2as we did not find these publications by means of our MEDLINE research. The third case, reported by Dwivedi et al,3 was well known to us. However, it was not included in our discussion, as it represents no complication of true acupuncture. The reported patient was mentally deranged and had an autoaggressive behavior with self-insertion of needles.

References
Schiff, AF A fatality due to acupuncture.Med Times1965;93,630-631
 
Nieda, S, Abe, T, Kuribayashi, R, et al Cardiac trauma as complication of acupuncture treatment: a case report of cardiac tamponade resulting from a broken acupuncture needle.Jpn J Thorac Surg1973;26,881-883
 
Dwivedi, SK, Gupta, LC, Narain, VS Self-inserted needle in the heart: localization by cross-sectional echocardiography.Eur Heart J1991;12,286-287
 

Figures

Tables

References

Kirchgatterer, A, Schwarz, CD, Höller, E, et al (2000) Cardiac tamponade following acupuncture.Chest117,1510-1511. [CrossRef]
 
Hasegawa, J, Noguchi, N, Yamasaki, J, et al Delayed cardiac tamponade and hemothorax induced by an acupuncture needle.Cardiology1991;78,58-63. [CrossRef]
 
Halvorsen, TB, Anda, SS, Naess, AB, et al Fatal cardiac tamponade after acupuncture through congenital sternal foramen [letter]. Lancet. 1995;;345 ,.:1175. [CrossRef]
 
Kataoka, H Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle.J Thorac Cardiovasc Surg1997;114,674-676. [CrossRef]
 
Schiff, AF A fatality due to acupuncture.Med Times1965;93,630-631
 
Nieda, S, Abe, T, Kuribayashi, R, et al Cardiac trauma as complication of acupuncture treatment: a case report of cardiac tamponade resulting from a broken acupuncture needle.Jpn J Thorac Surg1973;26,881-883
 
Dwivedi, SK, Gupta, LC, Narain, VS Self-inserted needle in the heart: localization by cross-sectional echocardiography.Eur Heart J1991;12,286-287
 
Cheng, TO Pericardial effusion from self-inserted needle in the heart [letter]. Eur Heart J. 1991;;12 ,.:958
 
Cheng, TO Acupuncture needles as a cause of bacterial endocarditis [letter]. BMJ. 1983;;287 ,.:689
 
Cheng, TO Subacute bacterial endocarditis following ear acupuncture [letter]. Int J Cardiol. 1985;;8 ,.:97. [CrossRef]
 
Cheng, TO Acupuncture treatment for angina [letter]. Cardiology. 1998;;90 ,.:152. [CrossRef]
 
Cheng, TO Acupuncture for relief of angina.Circulation1998;98,2357-2358. [CrossRef]
 
Cheng, TO Acupuncture risk [letter]. Med Tribune. 1988;;29(34) ,.:16
 
Cheng, TO Acupuncture and acquired immunodeficiency syndrome [letter]. Am J Med. 1989;;87 ,.:489
 
Schiff, AF A fatality due to acupuncture.Med Times1965;93,630-631
 
Nieda, S, Abe, T, Kuribayashi, R, et al Cardiac trauma as complication of acupuncture treatment: a case report of cardiac tamponade resulting from a broken acupuncture needle.Jpn J Thorac Surg1973;26,881-883
 
Dwivedi, SK, Gupta, LC, Narain, VS Self-inserted needle in the heart: localization by cross-sectional echocardiography.Eur Heart J1991;12,286-287
 
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