HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kataoka, H. Search for Related Content PubMed PubMed Citation Articles by Kataoka, H.

J Thorac Cardiovasc Surg 1997;114:674-676
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

CARDIAC TAMPONADE CAUSED BY PENETRATION OF AN ACUPUNCTURE NEEDLE INTO THE RIGHT VENTRICLE

Oita, Japan

From the Department of Internal Medicine, Nishida Hospital, Oita, Japan.

Received for publication March 17, 1997 accepted for publication March 27, 1997. Address for reprints: Hajime Kataoka, MD, Internal Medicine, Nishida Hospital, 3-3-24 Ohte machi, Saiki city, Oita 876, Japan.

Acupuncture therapy, an ancient Chinese art, has been acknowledged throughout the world as a valid clinical procedure. In Japan, acupuncture needles are sometimes left embedded permanently in the musculature to relieve myalgia or neuralgia. ¹ In the case described here, traumatic cardiac tamponade was caused by an acupuncture needle, which had presumably migrated from a distant part of the body via the venous route and eventually penetrated the right ventricular free wall. X-ray computed tomographic imaging confirmed that cardiac tamponade had been caused by the needle.

Clinical summary.

A 69-year-old woman was admitted to Nishida Hospital with chest oppression, dyspnea, and cold sweating. At another clinic, she had been receiving acupuncture therapy (embedment of needles in the musculature) about one to three times per month for 10 years because of chronic upper and lower back pain. The latest acupuncture session had been conducted 2 months before the present admission to our hospital. The number of acupuncture needles (made of silver or stainless steel, each about 3 cm long and 0.05 cm in diameter) embedded in the musculature around the back of the neck to the shoulder and the lower back in each session ranged from one to five.

On physical examination the patient had no fever and had pulsus paradoxus with a maximal systolic blood pressure of 80 mm Hg. Jugular venous distention and mild peripheral edema were present. The heart sounds were distant, but a friction rub was not audible. Chest and abdominal roentgenograms showed many embedded needles around the cervical and lumbar vertebrae. Several needles were superimposed on the lung field and the cardiac silhouette. The exact relationship between the needles and cardiac structures was not apparent on plain x-ray films and fluoroscopic examination of the chest. Transthoracic echocardiography revealed massive pericardial effusion with early diastolic collapse of the right ventricle. Because of the patient's hemodynamic deterioration, a drainage tube was introduced into the pericardial space on an emergency basis, resulting in efflux of bloody effusion and prompt clinical improvement. The nature of the pericardial fluid suggested traumatic injury to the heart, and an acupuncture needle was considered to be the cause. Close echocardiographic reexamination including the transesophageal mode in addition to the transthoracic method failed to find any acupuncture needle in or around the cardiac structures. However, x-ray computed tomographic imaging with contrast medium disclosed the metal-density material in the right ventricle, which stuck into the liver through the right ventricular free wall (Fig. 1, C to F). There were three needles in the pulmonary vasculature (one needle in the proximal right pulmonary artery is shown in Fig. 1, A).

View larger version (672K): [in this window] [in a new window]   Fig. 1. Several horizontal slices of contrast x-ray computed tomographic images at the levels of proximal pulmonary artery (A), lower half of the heart (B to E) and upper portion of the liver (F). Single arrow indicates metal-density material in the proximal pulmonary artery, and double arrows show metal-density material in the right ventricle, which extends into the upper portion of the liver. LV, Left ventricle; RV, right ventricle.

Discussion.

The heart or great vessels may be severely damaged by objects of unimpressive size or appearance. ² Examination of the literature shows that pins and needles often injure the heart, sometimes resulting in life-threatening cardiac tamponade. ² One of the most striking aspects of acupuncture therapy is the virtual absence of life-threatening side effects and complications resulting from its use. ³ However, it would be expected that life-threatening cardiovascular complications like those in this report (i.e., cardiac tamponade) could result from the use of acupuncture needles. A previous report ⁴ described a serious complication as a consequence of applying needles to the thorax directly, which caused cardiac injury and tamponade. Several pathways by which the acupuncture needle could have reached the heart can be considered, ² but we believe that in my patient the needle reached the right ventricle via the bloodstream from a distant region, eventually penetrating the free wall, because of the location of the acupuncture therapy and the coexistence of several needles in the pulmonary vasculature. In patients such as this, surgical removal of the pins or needles in the heart should be attempted because of the high mortality rate of needle-related cardiac injury. ² To facilitate successful removal of a needle from the heart, it is necessary to define the precise location of the needle before or during the operation. Ultrasonography has been reported to be useful for the evaluation and management of patients with foreign bodies in the heart, ⁵ although I failed to find the cardiac needle before operating using this method. Instead, x-ray computed tomography with contrast medium enabled me to locate the needle in the heart and greatly facilitated its successful removal, although the image was accompanied by an object-related artifact.

In conclusion, physicians involved in acupuncture therapy should keep in mind the possible serious cardiac complications reported here. Contrast x-ray computed tomography may be useful for imaging the needle in the heart and great vessels.

Acknowledgments

I thank Drs. Yoshiaki Mori and Tetsuo Hadama of the Department of Cardiovascular Surgery at the Oita Medical University for their help in treating the patient.

References

1. Shiraishi S, Goto I, Kuroiwa Y, Nishio S, Kinoshita K. Spinal cord injury as a complication of acupuncture. Neurology 1979;29:1188-90. [Abstract/Free Full Text]
   
2. Schechter DC, Gilbert L. Injuries of the heart and great vessels due to pins and needles. Thorax 1969;24:246-53. [Abstract/Free Full Text]
   
3. Rapson LM. Acupuncture: a useful treatment modality. Acupunc Res Q 1984;8:15-27.
   
4. Rosted P. Literature survey of reported adverse effects associated with acupuncture treatment. Am J Acupunc 1996;24:27-34.
   
5. Harrison LH Jr, Kisslo JA Jr, Sabiston DC Jr. Extraction of intramyocardial foreign body utilizing operative ultrasonography. J Thorac Cardiovasc Surg 1981;82:345-9.[Abstract]
   

This article has been cited by other articles:

				J. I. Gold, C. D. Nicolaou, K. A. Belmont, A. R. Katz, D. M. Benaron, and W. Yu Pediatric Acupuncture: A Review of Clinical Research Evid. Based Complement. Altern. Med., January 10, 2008; (2008) nem181v1. [Abstract] [Full Text] [PDF]

				T. O. Cheng and A. Kirchgatterer Cardiac Tamponade Following Acupuncture Chest, December 1, 2000; 118(6): 1836 - 1837. [Full Text] [PDF]

				A. Kirchgatterer, C. D. Schwarz, E. Holler, C. Punzengruber, P. Hartl, and B. Eber Cardiac Tamponade Following Acupuncture Chest, May 1, 2000; 117(5): 1510 - 1511. [Abstract] [Full Text] [PDF]

				K. J. Kemper, R. Sarah, L. MPH, E. Silver-Highfield, L.{s. E. Xiarhos, L. Barnes, and C. Berde On Pins and Needles? Pediatric Pain Patients' Experience With Acupuncture Pediatrics, April 1, 2000; 105(4): 941 - 947. [Abstract] [Full Text]

This Article Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kataoka, H. Search for Related Content PubMed PubMed Citation Articles by Kataoka, H.