Stingray Barb Injury: A Cause of Late Coronary Occlusion and

Ann Thorac Surg
2013;96:1875–7
CASE REPORT
SAUNDERS ET AL
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subsequent ventricular fibrillation. Furthermore, postmortem studies have shown that pacemaker implantation
does not prevent sudden death in patients with heart
block caused by this type of tumor. Thus, surgical intervention should always be indicated.
To our knowledge, only 5 ante mortem diagnoses and
resections of cystic tumors of the AV node region have
been reported [7,8]. In our case, the anterior minithoracotomy approach was an excellent route for the right
atrium and provided us with a satisfying field of view.
In conclusion, because the worst complication with this
tumor is sudden death, we believe that complete resection is essential, even if subsequent pacemaker implantation becomes necessary.
Fig 2. Immunohistochemical findings: diffuse expression of (A) widespectrum cytokeratins (100), (B) epithelial membrane antigen
(400), and (C) calcitonin (250).
diastase-resistant proteinaceous material that stained
positive with periodic acid–Schiff (Fig 1). They were
surrounded by dense fibrous stroma showing a focal
lymphocytic reaction and small solid nests of squamous
and sebaceous cells (Fig 1). At immunohistochemical
analysis, all the cells expressed wide-spectrum cytokeratins and epithelial membrane antigen; sporadic cells
were positive for calcitonin and serotonin; staining was
negative for calretinin (Fig 2) [3–6].
Comment
Cystic tumor of the AV node can be defined as a
congenital multicystic lesion located at the base of the
interatrial septum. The differential diagnoses can include
bronchogenic cysts, ectopic thyroid (struma cordis), teratomas, and metastatic adenocarcinomas. The mean age
at presentation is 38 years (range, birth to 78 years) and
women are more frequently affected than men (approximately 3:1). Two thirds of patients present with complete
heart block, 15% with lesser degrees of AV block, and 10%
with sudden death even without a history of heart block.
The literature reports tumor sizes varying from 0.5 mm to
30 mm. To make an ante mortem diagnosis, special
mention should be paid to female patients with electrocardiographic evidence of heart block with narrow QRS
complexes (limited to the AV node). The cause of lethal
arrhythmia in patients with cystic tumor of the AV node
region is still controversial, without a clear relationship
between tumor size and the occurrence of arrhythmia.
Hypotheses that explain why lethal arrhythmia occurs are
based on excessive distention of the ventricle with
Ó 2013 by The Society of Thoracic Surgeons
Published by Elsevier Inc
1. Paniagua JR, Sadaba JR, Davidson LA, Munsch CM. Cystic
tumour of the atrioventricular nodal region: report of a case
successfully treated with surgery. Heart 2000;83:E6.
2. Saito S, Kobayashi J, Tagusari O, et al. Successful excision of a
cystic tumor of the atrioventricular nodal region. Circ J
2005;69:1293–4.
3. Jialong G, Shunqing Z, Chenyi L, Yanmei J. Surgical treatment
of a giant cystic tumor of the atrioventricular nodal region.
Interact Cardiovasc Thorac Surg 2009;8:592–3.
4. Burke AP, Anderson PG, Virmani R, et al. Tumors of the
atrioventricular nodal region. A clinical and immunohistochemical study. Arch Pathol Lab Med 1990;114:1057–62.
5. Fine G, Raju U. Congenital polycystic tumor of the atrioventricular node (endodermal heterotopia, mesothelioma): a histogenetic appraisal with evidence for its endodermal origin.
Hum Pathol 1987;18:791–5.
6. Nojima Y, Ishibashi-Ueda H, Yamagishi M. Cystic tumour of
the atrioventricular node. Heart 2003;89:122.
7. Russo MJ, Martens TP, Hong KN, et al. Minimally invasive
versus standard approach for excision of atrial masses. Heart
Surg Forum 2007;10:E50–4.
8. Owais TA, F€arber G, Garbade J, Mohr FW. Excision of a left
atrial myxoma via a minimally-invasive technique: a possible
routine access. Interact Cardiovasc Thorac Surg 2011;12:875–7.
Stingray Barb Injury: A Cause of
Late Coronary Occlusion and
Stent Failure
Craig R. Saunders, MD, Enrique Saro, MD,
Parag Patel, MD, John Swidryk, MD,
Victor O. Bacani, MD, Mark J. Russo, MD, MS, and
Jay H. Stone, MD
Department of Cardiothoracic Surgery, Barnabas Heart Institute,
Newark Beth Israel Medical Center, Newark, and Department of
Cardiology and Department of Radiology, Barnabas Heart
Institute, Community Medical Center, Toms River, New Jersey
Stingray injuries to the heart are rare, and survivors of
this injury are even rarer. To date, there are only three
reported survivors of this mode of penetrating cardiac
Accepted for publication Feb 15, 2013.
Address correspondence to Dr Saunders, Department of Cardiothoracic
Surgery, Barnabas Heart Institute, Newark Beth Israel Medical Center, 201
Lyons Ave, Ste G5, Newark, NJ 07112; e-mail: [email protected].
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2013.02.052
FEATURE ARTICLES
References
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CASE REPORT
SAUNDERS ET AL
STINGRAY BARB INJURY
injury, all inflicted by the living animal itself. The
following is a report of a stingray injury, inflicted by a
human, causing coronary complications 17 years after the
injury was sustained.
(Ann Thorac Surg 2013;96:1875–7)
Ó 2013 by The Society of Thoracic Surgeons
L
ive stingray injuries are not uncommon. Approximately 750 to 1,500 are reported in the United States
annually, involving either the trauma of the puncture
wound or the envenomation from toxic glands running
the length of the stingray barb [1]. However, stingray
injuries to the heart are rare, and survivors of this injury
are even rarer. To date, there are only three reported
survivors of this mode of penetrating cardiac injury [2–4].
FEATURE ARTICLES
A 44-year-old man, otherwise healthy, presented to the
emergency room in February 2010 with an acute inferior
wall myocardial infarction, secondary to an isolated
total occlusion (Fig 1A) of the proximal right coronary
artery (RCA). There was no suggestion of atherosclerotic
disease in the distal right or in the left coronary system.
The lesion in the proximal RCA was emergently stented
with a Promus Everolimus-Eluting coronary stent (Boston
Scientific, Natick, MA), without complications, and with
full restoration of luminal diameter and resolution of the
acute infarction (Fig 1B).
The patient did well for 6 months but was admitted in
August 2010 with recurrent anginal symptoms. Repeat
catheterization showed in-stent stenosis, which was
reopened by deploying a Taxus Paclitaxel-Eluting stent
(Boston Scientific) within the previously placed Promus
stent, with full restoration of luminal diameter. In addition, a foreign body was identified in close proximity to
the stenosis (Fig 2).
Additional history revealed that the patient had been
stabbed in the chest with a dead stingray barb 17 years
previously. The patient’s recollection was that the majority of the stingray barb came out in the attacker’s hand,
but it was possible some had broken off in the chest.
Medical records were no longer available from that hospitalization, but according to the patient, he was
Fig 1. Angiogram showing totally occluded
right coronary artery on the (A) left and the
(B) opened vessel after stenting.
Ann Thorac Surg
2013;96:1875–7
hospitalized and observed without any intervention. Four
days after admission, he was discharged home, asymptomatic, with the apparent assumption that no foreign
body remained in the chest.
On September 14, 2010, after a 30-minute run, the patient experienced chest pain and shortness of breath.
He was again was admitted to the cardiac unit. A computed tomographic angiogram identified the foreign
body, consistent with the history of a stingray barb, lying
in the intraatrial septum, directly adjacent to the RCA
stent (Fig 3). Evaluation of intrastent stenosis was not
possible.
On September 22, 2010, the patient was electively
taken to the operating room for the planned procedure
of removal of the foreign body and grafting of the
RCA. The heart was exposed through a full sternotomy.
There were mild pericardial adhesions and an intrapericardial tract from the penetrating stingray barb
coming from the mid-anterior right chest. This tract was
surgically divided at the level of the pericardium,
leaving a few millimeters of the visible stingray barb
protruding from the heart anteriorly in the atrial ventricular groove.
With the heart beating, a meticulous dissection was
begun by sharp dissection of the serrated edges of
the stingray barb from a thickened fibrotic reaction surrounding the barb. At the level of the RCA, the barb was
intimately adhered, and a small amount of arterial
bleeding was controlled with a single Prolene suture
(Ethicon, Inc., Somerville, NJ).
At this point we converted to an on-pump procedure
and did the remainder of the dissection with the patient
under cardiopulmonary bypass with cardioplegic cardiac
arrest. The course of the stingray barb was through the
pericardium, over the top of the right atrium, between the
proximal RCA and the right ventricle, and down the atrial
ventricular groove, stopping adjacent to the aortic root
and the base of the anterior leaflet of the mitral valve.
Upon removal of the barb, one of the retroserrations of
the barb was actually engaged in the stent, causing disruption of the RCA. The coronary was ligated proximally
and distally to the stent, and an aortocoronary bypass
was performed in the standard fashion with a reversed
Ann Thorac Surg
2013;96:1875–7
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Fig 2. Restenosis of the right coronary artery with stingray barb in
close proximity.
saphenous vein graft from the proximal aorta to the
portion of the RCA near the acute margin of the heart.
The postoperative course was uneventful; the right
ventricular function improved to normal, and the patient
was discharged home on the fifth postoperative day.
Comment
This patient’s stingray injury is unique. It is primarily a
penetrating stab wound with a nonviable, nonvenomous
barb, inflicted by another human being, and without the
envenomation that usually accompanies stingray injuries.
Therefore, this injury was not associated with the usual
inflammatory response and tissue necrosis that can
accompany an attack from a live stingray.
This fact, along with the fact that the barb broke off at
the level of the myocardium and remained remarkably
and asymptomatically imbedded in nonvital areas of
the heart for 17 years, obviously not only saved this
patient’s life but also saved his attacker from a murder
charge.
The stingray barb is a remarkable feat of bioengineering. It is stiletto thin and sharp, and its edges are
lined with backward-pointing, harpoonlike, retroserrations (Fig 4A) that are anchored in soft tissue, preventing
its easy removal without severe tissue damage (Fig 4B).
The patient was free of other coronary disease.
The mechanism of coronary artery occlusion from the
presence of a long-standing foreign body, with the
notable exception of intracoronary stents, has never been
reported to our knowledge. It is postulated, however, that
slow migration of the foreign body and the surrounding
fibrotic reaction impinging on the lumen would be a
likely mechanism of action.
End-to-end reconstruction of the RCA after removal of
the stent was not feasible because of the length involved.
The right internal mammary artery could not be used
because of the old penetrating injury of the chest wall.
Therefore, a short segment of a reversed saphenous vein,
without valves or size change, was grafted in the standard
fashion from the proximal aorta to the RCA just distal to
the ligation.
References
Fig 3. Computed tomography reconstructions show the stingray barb
in relation to the stent and the cardiac chambers.
1. Diaz JH, Tm PH. The Epidemiology Evaluation and Management of Stingray Injuries. J La State Med Soc 2007;156:198–204.
2. Weiss BF, Wolfenden HD. Survivor of a stingray injury to the
heart. Med J Aust 2001;175:33–4.
3. Ronka EKF, Roe WF. Cardiac wound caused by the spine of
the stingray. Mil Surgeon 1945;97:135–6.
4. Parra MW, Costantini EN, Rodas EB, et al. Surviving a
transfixing cardiac injury caused by a stingray barb. J of
Thoracic and Cardiovascular Surgery 2010;139:115–6.
FEATURE ARTICLES
Fig 4. (A) The stingray barb was unchanged after 17 years of being
imbedded in the (B) myocardium.