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1998 Presentations for the Poster and Vignette Sessions
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CARDIAC EMBOLIZATION. Lyle Ignace, MD, Marilyn Schapira, MD. Medical College of Wisconsin, Milwaukee, WI.

Case: A 50­year­old man presented from an outside hospital for continued medical management of presumed acute pulmonary embolism. Shortly after transfer, the patient developed abrupt onset of sharp, pleuritic, right sided chest pain worsened by lying supine and causing shortness of breath. His examination was significant for tachycardia, hypotension, tachypnea, diaphoresis and in respiratory distress. The patient had distended neck veins and clear lung fields bilaterally with normal first and second heart sounds without extra heart tones. An AP chest radiograph revealed a metallic foreign body along the right border of the cardiac silhouette. The twelve lead ECG demonstrated three mm concave upward ST segment elevations in the inferior and precordial leads. Echocardiography was performed showing a dilated, diffusely hypokinetic right ventricle with grossly normal left ventricular function without evidence of pericardial effusion, no foreign body was visualized. Laboratory studies revealed bicarbonate 11 mEq/L, BUN 68 mg/L, creatitine 6.9 mg/L, INR 13.45, AST 11,155 U/L, ALT 4049 U/L, and Hb 8.5 mg/dl. Pulmonary artery catheter readings demonstrated equalization of diastolic compromise. Pericardiocentisis was performed immediately and yielded 400 cc of grossly hemorrhagic fluid. CT scan of the chest demonstrated the metallic foreign body to be within the posterior wall of the right ventricle.

The patient had undergone an open reduction internal fixation procedure for a comminuted distal left radius fracture four years prior to admission. Two Kirschner wires were utilized for the radius fixation. Current radiographs of left wrist show the presence of only one Kirschner wire. Thoracotomy was performed revealing a 2.5 cm Kirschner wore protruding from the right ventricle.

Discussion: Kirschner wire migration causing acute pericarditis complicated with pericardial tamponade is a rare event. Wires have been shown to migrate to major vascular structures including subclavian artery, ascending aorta, pulmonary artery and the heart with fatal outcomes.

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