Case presentation
Institutional review board approval for reporting this case and the need
for informed consent were waived as per the institution regulation An
otherwise healthy, 32-year-old male was admitted electively to our
department with chest pain and shortness of breath on moderate exertion
that was progressing with time over one year. His initial chest X-Ray
showed a foreign body at the apex of the heart. On inquiry, the patient
gave a history of Nail Gun Injury to the chest four years ago, which
caused a very small wound in the left side of the chest that had minimal
bleeding and some pain for two days that was relieved by pain killers.
He did not seek any medical advice afterward since the pain resolved and
he continued to be asymptomatic until one year ago when he started to
have chest pain and shortness of breath on severe exertion that
progressed over the year to occur with moderate exertion. Echocardiogram
showed preserved left ventricular function with a hyperechoic foreign
body at the posterior basal part of the left ventricle (Figure 1). All
valves had normal structure and function. Computerized Tomography (CT)
of the chest with contrast was performed to better understand the exact
position of the foreign body and its relation to the surrounding
structures. The chest CT showed a long narrow white shadow (measuring 5
cm) penetration the medial part of the left lung and the posterior basal
part of the left ventricle with a fibrous band surrounding the foreign
body (Figure 2). Coronary angiography was performed to rule out any
coronary injury given the patient presentation with unstable angina. The
coronary angiogram revealed a fistula between the tip of posterolateral
branch of the right coronary artery and the left lower lobe posterior
basal segmental branch of the left pulmonary artery (Figure 3).
The decision was made to take the patient to the OR for removal of the
foreign body and ligation of the coronary pulmonary fistula. After
median sternotomy, the pericardium was then opened, which interestingly
showed no bleeding or effusion. The heart was left for examination and
showed a thick fibrous band that 2 cm wide connecting the posterior
basal part of the left ventricle and the posterior pericardium, Heparin
was administered and cardiopulmonary bypass (CPB) was established using
ascending aortic cannulation and two-stage venous cannulation. The heart
was drained and the operation was performed on a beating heart. The
fibrous band was resected circumferentially off the posterior
pericardium and revealed the nail that was protruding from the medial
part of the left lung. The nail (Figure 4) was pulled off the lung
tissues and then the other end was pulled off the left ventricular wall
with difficulty. The two ends of the fibrous band on both sides (the
heart and the posterior pericardium and left pleura) that are containing
the bridging collaterals of the fistula were ligated using 2 U-shaped
3-0 prolene mattress sutures supported with pledgets (Figure 5). The
patient had non-eventful postoperative course and was discharged home
after 4 days in stable condition.