Introduction:

Discussion

Suicide is a significant public health concern that claims more lives annually than interpersonal violence and war. Depression, particularly among elderly adults, is a leading contributor to suicide attempts [6]. The social stigma surrounding mental illness and suicide often results in underreporting, making it difficult to accurately assess the scale of the problem [4]. Self-destructive behavior is sometimes associated with medical conditions like Lesch-Nyhan syndrome, de Lange syndrome, Gilles de la Tourette's syndrome, and cognitive impairments. Psychiatric disorders such as personality disorders, dissociative disorders, schizophrenia, major depressive episodes, mania, and gender dysphoria also play a role in suicidal behavior [2]. In many cases involving the self-embedding of needles into the heart, substance use (drugs or alcohol) is a common factor, exacerbating impaired judgment and risky behavior [7]. However, in our patient, there was no evidence of substance use, but underlying conditions like depression and ADHD may have contributed to her actions.

Trauma involving the heart, especially from sharp objects such as needles, is rare but poses severe risks. Self-inflicted injuries involving needle insertion into the chest, while uncommon, have been documented. Schechter and Gilbert (1969) reported that 56% of injuries involving pins and needles in the heart and great vessels were accidental, while 33% were intentional acts of self-harm [8]. From 1967 to 2013, only 40 cases of sewing needles impaling the heart were reported, with 90% occurring in patients with significant psychiatric conditions [2]. Our case involved a suicide attempt using a syringe needle, contributing to a unique form of cardiac trauma.

Cardiac trauma from penetrating objects typically affects the right ventricle, followed by the left ventricle, right atrium, and left atrium. The prognosis depends on factors like the type of object, the location of the injury, associated pericardial damage, and adjacent lung involvement [9]. Symptoms of penetrating cardiac trauma often include chest pain and shortness of breath, although some patients may remain asymptomatic [10]. In our case, the patient exhibited typical symptoms of difficulty breathing and chest discomfort. Immediate diagnosis and intervention are crucial, as the most common fatal complication, pericardial tamponade, can occur when the pericardium fills with blood due to a puncture wound.

Diagnosis of cardiac trauma is achieved through imaging techniques, with transthoracic echocardiography (TTE) being a preferred method due to its high accuracy and non-invasive nature [11]. TTE can localize foreign objects within the heart and provide critical information about the object's size, position, and movement, assisting in preoperative planning [5]. In this case, TTE effectively localized the needle in the right ventricle, enabling its safe manual extraction during surgery.

Managing cardiac trauma from self-inflicted injuries requires a multidisciplinary approach, involving collaboration between cardiologists, cardiothoracic surgeons, radiologists, psychiatrists, and emergency care providers [12]. The treatment decision-making process takes into account several factors, including the patient’s clinical presentation, the size and location of the foreign object, the risk of complications, and the patient’s overall psychiatric and medical condition [13]. Treatment options for foreign body removal from the heart can range from minimally invasive surgery to open-heart surgery, and the decision is influenced by the characteristics of the injury and patient stability [14].

Minimally Invasive Surgery such as thoracoscopy or video-assisted thoracic surgery (VATS), can be utilized in certain cases to remove foreign objects without the need for open surgery; They are especially useful for objects located in accessible areas of the chest or heart [15]. In cases of needle insertion, however, the risk of damage to surrounding structures may still necessitate a more invasive approach. Open-Heart Surgery uses for foreign bodies like sewing needles or syringe tips that penetrate deeply into the heart tissue, open-heart surgery is often necessary. In cases where the needle is embedded within the myocardium, especially if it is causing hemodynamic instability or is at risk of migration, open surgery allows for direct visualization and safe removal. Cardiopulmonary bypass (CPB) may be required if the object is not easily accessible or poses a risk to the heart's structural integrity [16]. In our patient’s case, the needle tip was visible on the surface of the heart, which allowed for successful manual extraction without CPB. In this case, after careful evaluation of the needle's position using transthoracic echocardiography (TTE), the surgical team decided on manual extraction due to the needle's accessibility and the patient's overall stability. Had the needle been more deeply embedded or posed greater risk, a more invasive procedure, possibly requiring CPB, would have been necessary.

Timely recognition and management of self-inflicted cardiac trauma are essential to prevent fatal outcomes. Although rare, this type of trauma requires immediate medical attention, and the successful outcome in our case highlights the importance of early intervention, accurate imaging, and appropriate surgical techniques in treating patients with self-inflicted penetrating cardiac injuries.

Conclusion

This report underscores the importance of considering intracardiac foreign objects in individuals with self-aggressive tendencies, demonstrating how early detection and intervention can save lives. The necessity of prompt surgical removal is emphasized as crucial. Additionally, echocardiography is highlighted as the primary noninvasive diagnostic tool. Rapid recognition of warning signs of self-aggressive behavior, combined with immediate medical response, is essential for effectively mitigating life-threatening complications.

Additional Information

Author Contributions

Zahra Ansari Aval: Conceptualization; project administration; supervision; writing – original draft.

zahraansariaval@gmail.com

Mahdi Rezaei: Data curation; resources; supervision; Methodology.

Dr.mrezaei98@gmail.com

Niki Mirhosseini: Data curation; resources; supervision; Methodology.

Nmirhosseini1@luc.edu

Seyed Mohsen Mirhosseini: Supervision; visualization; writing – original draft.

mohsenmirhosseini@sbmu.ac.ir

Disclosure

Study Limitations: This study has no notable limitations. The case was managed effectively with appropriate diagnostic and surgical interventions, and all relevant factors were thoroughly considered. Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Acknowledgment 
We acknowledge the use of ChatGPT for assistance in correcting grammatical errors and clarifying certain sentences in the manuscript.

ORCID

Seyed Mohsen Mirhosseini        

https://orcid.org/0000-0002-2903-682X

Mahdi Rezaei

https://orcid.org/0000-0003-0409-2072