INTRODUCTION: Our patient is a 66 year old man who went for an outpatient MRI for chronic low back pain. Two weeks later he presented to the ER in shock. We present a case of delayed cardiac tamponade with a very rare iatrogenic cause.
CASE PRESENTATION: CASE REPORTA 66-year-old man presented to the ER with chest pain, low blood pressure and severe shortness of breath.His medical history was significant for well controlled hypertension and diabetes. His initial physical and lab work up was unrevealing. His cheat X ray and chest CT was normal. The presumptive diagnosis was ACS. Patient was transferred to ICU for further management. In the ICU his systolic pressures dropped to 60’s despite pressors and fluids. Patient was hypoperfusing, venous engorgement was noted on his anterior chest and his heart sounds seemed distant. A TTE revealed pericardial effusion with right ventricular collapse. Emergent thoracotomy and pericardial window was performed at bedside. About 400 cc of hemorrhagic fluid was drained; subsequently, hemodynamic stability was restored. A follow up echocardiogram revealed two echogenic densities coursing through the right atrium into the right ventricle. These densities were confirmed by TEE. On review of the chest CT obtained in ER, a possible foreign body was seen coursing from the right ventricle to the hepatic vein. Interventional radiology consult retrieved a guidewire via internal jugular vein access. The extracted guidewire was a small caliber, long wire and magnetic. The patient remained stable after the removal of the wire and was transferred to a step-down unit. After detailed review of his history, the patient had a motor vehicle accident 12 years previously. This was complicated by bilateral deep vein thromboses and PE. He had an IVC filter placed and possible central line placement.Most likely that is when the guidewire was left in the patient. He had no information about the wire.
DISCUSSIONS: Hemorrhagic pericardial effusions with tamponade have few etiologies. In a recent series from the United States, the authors evaluated 96 cases of cardiac tamponade with hemorrhagic pericardial effusions. 31 % required pericardiocentesis. In this series bloody pericardial effusion etiologies were mostly iatrogenic. Malignancy, complications of acute myocardial infarction, and idiopathic disease were also prevalent. Tuberculosis should be strongly considered in endemic areas outside the US. Foreign objects left inside the body causing cardiac tamponade are a very rare cause and mostly iatrogenic.
CONCLUSION: More than 5 million central lines are inserted in the US every year. One of the complications noted is loss of guidewire. There are no good statistics on how often this complication happens. We also don't know how many people are living with guidewires inside them but unaware of it. It is most likely that our patient was living with a 20 cm guide-wire inside him for the last 12 years. The MRI caused this wire to puncture his myocardium causing slow leaking of blood which caused a cardiac tamponade 2 weeks later. Prompt recognition and treatment saved his life.
DISCLOSURE: Yashvir Sangwan, No Financial Disclosure Information; No Product/Research Disclosure Information