Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient

Research Article | DOI: https://doi.org/10.31579/2641-0419/127

Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient

  • Ronald Orozco 1
  • Avra S. Laarakker 2*
  • Brian Castlemain 3
  • 1 Division of General Surgery. University of New Mexico, Albuquerque, NM, USA
  • 2* Division of Plastics, Hand, and Burn Surgery, University of New Mexico, Albuquerque, NM, USA
  • 3 Division of Cardiothoracic Surgery, University of New Mexico, Albuquerque, NM, USA

*Corresponding Author: Avra S. Laarakker, Division of Plastics, Hand, and Burn Surgery, University of New Mexico, UNM School of Medicine MSC 10 5610, 1 University of New Mexico Albuquerque, New Mexico 87131

Citation: Ronald Orozco, Avra S. Laarakker, Brian Castlemain (2021) Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient. J. Clinical Cardiology and Cardiovascular Interventions, 4(5); Doi:10.31579/2641-0419/127

Copyright: © 2021 Avra S. Laarakker, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 12 January 2021 | Accepted: 19 February 2021 | Published: 25 February 2021

Keywords: intracardiac needle; self-insertion; acupuncture; darning needle

Abstract

Objective: We report a case of self inserted needle into the left ventricle of the heart and a description of our surgical intervention in a psychiatric patient without decision-making capacity. We discuss issues regarding obtaining consent in this patient with a sub-acute presentation, report our operative approach, and summarize a treatment approach based on a review of current literature.

Methods: A PubMed search using terms “needle, “heart”, “insertion”, “intracardiac foreign object”, yielded 69 relevant papers. 67 of these were case reports yielding 72 individual cases. Age, gender, cause of the needle entry (Accidental Plus (A+), Intravenous Drug User [IVDU], Self-inflicted (SI)), type of needle, location in heart, neuropsychiatric history, treatment, and outcome were documented.

Results: Within the SI category, there were a total of 28 cases, 89.3% had a neuropsychiatric history whereas only there were only 2 such patients in both the IVDU and A+ group. The location of the needle in the heart in all 72 cases was as follows: right ventricle 40.3%, other 20.8%, left ventricle 19.4 %, ventricle and interventricular septum 16.7% and the right and left atrium were each 1.4 %. In all three groups (n=72), 77.8% of patients underwent surgery, with 92.9% having a stable outcome.

Conclusion: Our case and review demonstrates that management of such cases, particularly when active mental health issues are present, requires a case-by-case evaluation and treatment as a specific standard of care has not been established. Surgical intervention appears to be the preferred management regardless of presentation with good outcomes.

Running Title: Intracardiac Self Insertion of a Darning Needle in a Psychiatric Patient

Introduction

Cases of needle self-insertion are not uncommon, and while common causes of chest pain should be considered, in patients with self-injurious or psychiatric history, this pathology should not be excluded. Currently there is no standard of care or guidelines for the management or treatment of needles within the heart. Our review finds that most cases undergo surgical intervention to remove the needle.

We report a case of needle self-insertion into the left ventricle of the heart in a patient with psychiatric illness. We describe our treatment approach by sternotomy and left ventriculotomy, and outline the difficulties encountered with this particular patient. Additionally, we present a review of the literature regarding all published cases, management of intracardiac needles, and specifics of this complex patient population and their presentation.

Case Description:

A 35 year old male with a history of schizophrenia, bipolar disorder, and methamphetamine abuse presented to the emergency department at our institution. He had been transferred from an inpatient psychiatric facility with complaints of sharp and persistent chest pain in the left anterior chest. The patient stated he was having a “heart attack.” He also stated that he had inserted a six centimeter sewing needle into his left anterior chest days prior to relieve the pain and “heal himself.” He had a long history of needle insertion into various areas of his body, believing this practice would improve his health. He was initially evaluated by the general surgery service for a number of needles in the epigastric area, noted on abdominal radiography. These were noted to be extraperitoneal and conservative measures were advised. A CT scan of the chest demonstrated a metallic foreign within the left ventricle, and the cardiothoracic surgical service was consulted (Figure 1).

Figure 1: CT Chest with contrast demonstrating intraventricular position of needle.

Notable findings on his evaluation included a troponin of 0.73 ng/cc, an unremarkable ECG, and a transthoracic echocardiogram that revealed a needle completely within the left ventricle, not involving left-sided valves and with no evidence of pericardial effusion. From the time of his arrival in the emergency department, and throughout his pre-surgical course, the patient was asymptomatic. He was admitted for observation and surgical planning. The patient was evaluated by the psychiatry service and deemed incapable of giving his own consent for surgery. Obtaining power of attorney required several days, but eventually consent was obtained, and the patient was taken to the operating room. Repeat echocardiography prior to operation revealed evidence of thrombus involving the needle and seemed to demonstrate migration of the needle anteriorly in the left ventricle (Figure 2).

Figure 2: Second Transthoracic Echocardiogram prior to operative intervention demonstrating intraventricular position of needle.

The patient underwent median sternotomy with cardiopulmonary bypass and cardiac arrest to retrieve the needle via a left ventriculotomy due to needle location (Figure 3).

Figure 3: Needle after surgical removal measuring 5.8 cm.

Operative findings included the intracavitary needle covered with thrombus, no pericardial effusion, and fibrosis in the area where the needle penetrated the pericardium into the heart. These findings were consistent with needle entry at an earlier time. The patient’s postoperative course was uneventful. During his postoperative psychiatric evaluation, the patient reported his desire to continue his self-insertion of needles, and he was transferred back to an inpatient psychiatric facility for further evaluation and treatment.

Materials and Methods:

To perform our literature review, a thorough search of PubMed using search terms “needle, “heart”, “insertion”, “intracardiac foreign object”, yielded 69 relevant papers. 67 of these were case reports yielding 72 individual cases. We included only papers describing “needles” as the intracardiac foreign body.

For each case, age, gender, cause of the needle entry (Accidental Plus, Intravenous Drug User [IVDU], Self-inflicted), type of needle, location in heart, neurologic or cognitive/psychiatric history (denoted as NeuroPsych in tables), treatment, and outcome, were documented. The category “Accidental Plus” was used for patients who were not IVDUs nor needle self-inserters. However, this did include trauma or intentional injury by another person. Patients who were IVDUs were categorized separately as these accounts were not purely accidental nor were they intentionally self-inflicted. When categorizing the location of the needle, we looked at all chambers of the heart and other locations, but defined needles involving the intraventricular septum as either left or right ventricle or both. We defined “other” location as extracavitary or not specified.

Results

Our review included 72 cases from 67 case reports [1-67]. For the “Accidental Plus” category there were a total of 34 cases. Of note, 17.6 percent, (6 out of 34) of these cases were acupuncture needles. It appears that in these acupuncture cases, the provider was an unlicensed acupuncturist. In the “Accidental Plus” category, 2.9% (1 of 34) had a neurologic or cognitive/psychiatric history. Among the IVDU category there were a total of 10 cases where only 10% (1 of 10) of these patients had a neurocognitive/psychiatric history.  Within the Self-Inflicted category, there were a total of 28 cases, 89.3% (25 of 28) had a neuropsychiatric history. In order of decreasing frequency, the location of the needle in the heart was as follows: right ventricle 40.3% (29 of 72), other 20.8% (15 of 72), left ventricle 19.4 % (14 of 72), ventricle and interventricular septum 16.7% (12 of 72) and the right and left atrium were each 1.4 % (1 of 72). Of note, in IVDUs the needle location was in the right ventricle in all cases. In all instances the atria were unlikely to be involved. In all three groups, treatment favoured surgical intervention with 77.8% (56 of 72) undergoing surgery with 92.9% (52 of 56) having a stable outcome. The missing patients here were either lost to follow up or outcome was not specified. There was one death in the Accidental Plus category, however the treatment of the patient was not specified. In the Self-Inflicted group, there were three deaths, however these patients were managed conservatively or the treatment was not specified. There did not appear to be a gender predominance in the individual categories or when looking at all three groups together. However, all the patients in the Acupuncture group were female. A summary of the Appendices can be seen in Table 1.

Table 1: 

Accidental Plus: 34 Reports

.

IVDU: 10 Reports

.

Self-Inflicted: 28 Reports

.

Totals: 72 reports

.

Please see individual categories and details in Appendices A-E.

Appendices: A.

Accidental Plus

 

Gender

Age

Needle Type

Cause

Neuropsych

Location

Treatment

Outcome

Actis Dato, Arslanian, Di Marzio, Filosso, Ruffini 32

M

2.5 Years 

Not Specified 

Accidental 

None Reported 

Left Ventricle 

Left anterior thoracotomy 

Stable 

M

9 Years

Not Specified 

Accidental 

None Reported 

Left Atrium 

Left thoracotomy 

Not Specified 

M

51 Years

Not Specified 

Accidental 

None Reported 

Pulmonary artery 

Conservative Treatment

Death: Cancer 

Affronti, Di Bella, Di Lazzaro, Capozzi, Scarnecchia, Ragni 33

M

30 Years

Sewing 

Accidental 

None Reported 

Left Ventricle lateral wall 

Sternotomy and heart dissection 

Stable 

Akpinar, Sayin, Karabag, Dogan, Aydin 34

-

34 Years

Safety Pin 

Accidental 

None Reported 

Left ventricle anterolateral wall 

Conservative management

Stable 

Choudhary, Pujar Venkateshacharya, Reddy 35

M

3 Years

Sewing 

Accidental 

None Reported 

Right heart across tricuspid 

Sternotomy and heart dissection 

Stable 

Darmawan 36

M

14 Years

Sewing 

Accidental 

None Reported 

Right Ventricle 

Sternotomy did not incise heart 

Stable 

Dong, Zhai, Li, Cui, Chen, Wang 37

F

13 Months

Sewing 

Accidental 

None Reported 

Right ventricle and interventricular septum 

Sternotomy and heart dissection 

Stable 

Ernst 38

F

44 Years

Acupuncture

Acupuncture

None Reported 

Right Ventricle

Not Specified 

Death 

Honikman, Chikwe, Tokita, Mittnacht 39

M

55 Years

14-gauge all metal hemodialysis cannulation needle,

hemodialysis access needle

None Reported 

Lateral Right ventricular wall, below tricuspid 

Ministernotomy and heart dissection 

Stable 

Hsia, Mahadevan, Brundage 40

F

54 Years

Wooden knitting needle 

Accidental 

None Reported 

Right Ventricle 

Sternotomy did not incise heart 

Stable 

Irdem, Baspinar, Gokaslan 41

M

3 Years

Not Specified 

Accidental 

None Reported 

Right Ventricle 

Anterior thoracotomy 

Stable 

Kataoka 42

F

69 Years

Acupuncture

Acupuncture

None Reported 

Right Ventricle

Sternotomy did not incise heart 

Stable 

Kim, Yang, Choi, Seo, Chun, Lee, Hong, Joo, Choi 31

F

61 Years

Acupuncture

Acupuncture

None Reported 

Not Specified 

Not Specified 

Not Specified 

Kobayashi, Hayashi, Sakata, Kobayashi 43

F

55

Needle like

Unknown 

None

Tricuspid

Sternotomy

Not

 

 

Years

foreign body 

 

Reported 

anterior leaflet 

and heart dissection 

Specified 

Lake, Puleston, Farquharson 44

M

53 Years

Endoscopic 

Accidental 

None Reported 

Left Ventricle into aortic arch 

Percutaneous 

Stable 

Linard, Marques, Bezon, Delaperriere, Germouty, Fenoll, de Vries 1

M

14 Years

Sewing 

Accidental 

congenital mental retardation

Posterior pericardial side below 4 pulmonary veins 

Thoracotomy

Stable 

Liu, Gilkeson, Markowitz, Schroder 45

M

46 Years

Suture

Surgical error 

None Reported 

Under pericardium 

Sternotomy did not incise heart 

Stable 

Mandegar, Ali Yousefnia, Rayatzadeh, Roshanali 46

M

36 Years

Sewing 

Domestic abuse 

None Reported 

Left Ventricle 

Sternotomy and heart dissection 

Stable 

Murakami, Okada, Nishida, Hamano 47

M

14 Years

Sewing 

Accidental 

None Reported 

Intraventricular Septum 

Sternotomy and heart dissection 

Stable 

Papadopoulos, Kouerinis, Giannakopoulou, Eleftherakis, Andreou, Azariades 48

M

3 Years

Tropical plant needle 

Accidental 

None Reported 

Right Atrium 

Thoracotomy

Stable 

Park, Shin, Choo, Song, Kim 49

F

49 Years

Acupuncture

Acupuncture

None Reported 

Right ventricular wall and interventricular septum 

Sternotomy and heart dissection 

Stable 

Potek, Wright 50

F

61 Years

Darning needle 

Accidental 

None Reported 

Left Ventricle 

Sternotomy and heart dissection 

Stable 

Sanchez, Bradfield, Traina, Wachsner 51

F

57 Years

Acupuncture

Acupuncture

None Reported 

Right Ventricle

Heart dissection 

Lost to f/u 

Sbokos, Azariades, Chlapoutakis, Vomvogiannis, Nomikos, Andritsakis 52

-

6 weeks

Sewing 

Accidental 

None Reported 

Left Ventricle through Intraventricular septum into Right Ventricle 

Median Sternotomy 

Stable 

-

2 Years

Not Specified 

Accidental 

None Reported 

Lateral side of Left chest wall 

Median sternotomy under ECC

Not Specified 

Schechter, Gilbert 23

M

34 Years

Not Specified 

Accidental 

None Reported 

Right ventricle and interventricular septum 

Left anterior thoracotomy 

Stable 

Schultz, Post, Plumley, O'Brien, DeCampli 53

M

10 Years

Sewing 

Accidental

None Reported 

Right Ventricle 

Sternotomy and heart dissection 

Stable 

Sola, Cateriano, Thompson, Neville 54

F

3 Months

Sewing 

Intentional parent abuse 

None Reported 

Not Specified 

Subxyphoid incision and removal 

Stable 

Talwar, Subramaniam, Subramanian, Kothari, Kumar 55

M

4 Years

Sewing 

Accidental 

None Reported 

Right ventricle and interventricular septum 

Thoracotomy 

Stable 

Tan, Azzi, Sharma 56

-

None Reported

hemodialysis cannulation needle

None Reported 

None Reported 

Not Specified 

Not Specified 

Not Specified 

Vazquez, Tapia, Revilla, San Roman 57

M

62 Years

Sewing 

Accidental 

None Reported 

Left Ventricle 

Not specified 

Not Specified 

Wigger, Stortecky, Most, Englberger 58

F

51 Years

Acupuncture

Acupuncture

None Reported 

Left Ventricle 

Sternotomy and heart dissection 

Stable 

Yanar, Aksoy, Taviloglu, Unal, Kurtoglu, Nisli 59

F

5 Years

Hooked knitting needle 

Accidental 

None Reported 

Right Ventricle 

Thoracotomy 

Asymptomatic VSD 

B

Intravenous drug use

 

Gender

Age

Needle Type

Cause

Neuropsych

Location

Treatment

Outcome

Al-Sahaf, Harling, Harrison-Phipps, Bille 60

M

39 Years

Hypodermic

IVDU needle

None Reported

Right Ventricle septal wall into mediastinum

Thoracotomy

Stable

Bompotis, Karkanis, Chatziavramidis, Konstantinidis, Dokopoulos, Lazaridis, Pyriochos 30

M

47 Years

insulin needle

IVDU needle

None Reported

Apex of Right Ventricle

Percutaneous

Stable

Danek, Kuchynka, Palecek, Cerny, Hlavacek, Lambert, Nemecek, Podzimkova, Linhart 61

M

27 Years

Not Specified

IVDU needle

None Reported

Apex of Right Ventricle

Conservative management, needle left in place

Stable

Fu, Chen, Liao, Shen 62

M

40 Years

Not Specified

IVDU needle

None Reported

Right Ventricle

Sternotomy did not incise heart

Stable

Gyrtrup, Andreassen, Pedersen, Mortensen 63

M

32 Years

Hypodermic Needle

IVDU needle

None Reported

Right Ventricle

Thoracotomy

Lost to follow up

LeMaire, Wall, Mattox 64

F

31 Years

27g hollow needle

IVDU needle

None Reported

Apex of Right Ventricle

Sternotomy did not incise heart

Stable

Low, Jenkins, Prendergast 65

M

28 Years

Not Specified

IVDU needle

None Reported

Right Ventricle

Conservative management

Stable

Ngaage, Cowen 2

F

22 Years

Not Specified

IVDU needle

Depression, attempted suicide

Right Ventricle

Conservative management, patient refused surgery

Stable

Steiner, Dhingra, Devries 66

M

24 Years

Not Specified

IVDU needle

None Reported

Right Ventricle

Percutaneous

stable

Thanavaro, Shafi, Roberts, Cowley, Arrowood, Cassano, Abbate 67

F

49 Years

Not Specified

IVDU needle

None Reported

Right Ventricle

Surgery: Sternotomy did not incise heart

Stable

C

Self inflicted

 

Gender

Age

Needle Type

Cause

Neuropsych

Location

Treatment

Outcome

Arslan, Colkesen, Akcan, Hilal, Meral 3 

M

46 Years

Tapestry needle

Self Inflicted

Depression

Apex to Left Ventricle

Not specified

Death, suicide

Chand, Sarju, Kumar, Singh 4

M

20 Years

Not Specified

Self Inflicted

History of suicidal tendencies

Apex

Sternotomy did not incise heart

Stable

Dwivedi, Gupta, Narain 5

M

40 Years

Not Specified

Self Inflicted

Hebephrenic-schizophrenic

Right Ventricle though interventricular septum into Left Ventricle

Median sternotomy under ECC

Not Specified

Gallerani, Ferrari, Magenta, Barboso, Antonelli, Manfredini 6

M

34 Years

Darning needle

Self Inflicted

Borderline personality disorder

Right Ventricle

Median sternotomy without ECC

Stable

Gungor, Duygu, Yildiz, Gul, Zoghi, Ozerkan 7

M

32 Years

Sewing

Self Inflicted

depression

Right Ventricle

Sternotomy bypass

Stable

Inoue, Iemura, Saga 8

F

47 Years

Not Specified

Self Inflicted

Depressive Psychosis

Left Ventricle and Right Ventricle

Median sternotomy without ECC

Not Specified

Jamilla, Casey 9

M

42 Years

Sewing

Self Inflicted

History of depression, suicide attempts, self harm

Left Ventricle

Surgery not indicated

Lost to f/u

Keogh, Oakley, Taylor 10

F

34 Years

Sewing

Self Inflicted

Depressive psychosis

Pericardium, Adventitia of ascending aorta

Median sternotomy, pericardiectomy

Not Specified

Keskin, Sen, Baysal, Kahraman 11

M

49 Years

Sewing

Self Inflicted

Schizophrenia

Apex to Left Ventricle

Sternotomy did not incise heart

Stable

Kishon, Pauzner, Dalith, Neufeld 12

F

32 Years

Not Specified

Self Inflicted

Suicide Attempt

Right Ventricle

Median sternotomy, pericardiectomy

Stable

F

32 Years

Not Specified

Self Inflicted

Suicide Attempt

Right Ventricle

Median sternotomy, pericardiectomy

Stable

Lin, Yoneyama, Takahashi-Igari, Ohto, Sakamoto 13

F

14 Years

Not Specified

Self Inflicted

Tuberous Sclerosis Complex- TAND

Right ventricle and interventricular septum

Sternotomy and heart dissection

Moderate left ventricular dysfunction

Mihmanli, Kurugoglu, Kantarci, Atakir, Akman 14

F

12 Years

Sewing

Self Inflicted

Attempted Suicide

Lateral wall of Left Ventricle

Median Sternotomy without ECC

Stable

Mochizuki, Sugita, Okamura, Iida, Mori, Shimada 15

F

17 Years

Not Specified

Self Inflicted

History of self harm

Right Ventricle

ECC and Fluoroscopy

Not Specified

Moon, Jo, Song, Kim 16

F

59 Years

Sewing

Self Inflicted

MDD, history of self injury

Right ventricle and interventricular septum

Sternotomy and heart dissection

stable to psych unit

Morrison, Heyworth 17

M

22 Years

Sewing

Self Inflicted

Personality disorder and depression

Through LAD into LV

Median sternotomy under ECC

Stable

Neely, Jeganathan, Campalani 18

M

30 Years

acupuncture

Self Inflicted

History of self harm

Right Ventricle

Sternotomy and heart dissection

Stable

Nishida, Tomita, Watanabe, Yasuda, Iino, Arai 19

F

72 Years

Not Specified

Self Inflicted

History of Dementia

Left Ventricle and Right Ventricle through the interventricular septum

Median sternotomy under ECC

Not Specified

Park, Jeong, Lee, Jeong 20

F

54 Years

Not Specified

Swallowed needle, self inflicted

None Reported

R Ventricle into septal leaflet

Sternotomy did not incise heart

Mild tricuspid regurgitation

Qian, Song, Li, Jiang 21

M

34 Years

Sewing

Self Inflicted

History of depression, self harm

Left Ventricle

Thoracotomy

Stable

F

62 Years

Sewing

Self Inflicted

Depression, suicide attempt

Right Ventricle

Thoracotomy

stable to psych unit

Sayin, Besirli, Arslan, Canturk 22

F

13 Years

Sewing

Self Inflicted

Prepsychotic episode and depression

Left Ventricle across interventricular septum

Median sternotomy without ECC

Not Specified

Schechter, Gilbert 23

F

34 Years

Not Specified

Self Inflicted

Depression

Anterior surface of Right Ventricle

Left anterior thoracotomy

Stable

F

29 Years

Sewing

Self Inflicted

None Reported

Pericardial fat over Right Ventricle

Left anterior thoracotomy

Stable

Sobnach S, Castillo F, Blanco Vinent R, Kahn D, Bhyat A 24

M

19 Years

Sewing needle

Swallowed needle, self inflicted

None Reported

Left Ventricle

Sternotomy did not incise heart

Stable

Tan, Brunswicker, Abdelraheem, Sheehan 25

F

39 Years

Sewing

Self Inflicted

Cerebral Palsy

Needle tip at myocardium

Palliative

Death: hypoxic brain injury

Ulas, Kocabeyoglu, Diken, Lafci, Yalcinkaya 26

F

25 Years

Sewing

Self Inflicted

Under antipsychotic treatment

Right Ventricle

Sternotomy and heart dissection

Stable

Vesna, Tatjana, Slobodan, Slobodan 27

F

20 Years

Sewing

Self Inflicted

Acute Psychosis

Left Ventricle across interventricular septum

Misdiagnosis

Death

 

D

Acupuncture

 

Gender

Age

Needle Type

Cause

Neuropsych

Location

Treatment

Outcome

Ernst 38

F

44 Years

Acupuncture

Acupuncture

None Reported

Right Ventricle

Not Specified

Death

Kataoka 42

F

69 Years

Acupuncture

Acupuncture

None Reported

Right Ventricle

Sternotomy did not incise heart

Stable

Kim, Yang, Choi, Seo, Chun, Lee, Hong, Joo, Choi 31

F

61 Years

Acupuncture

Acupuncture

None Reported

Not Specified

Not Specified

Not Specified

Park, Shin, Choo, Song, Kim 49

F

49 Years

Acupuncture

Acupuncture

None Reported

Right ventricular wall and interventricular septum

Sternotomy and heart dissection

Stable

Sanchez, Bradfield, Traina, Wachsner 51

F

57 Years

Acupuncture

Acupuncture

None Reported

Right Ventricle

Heart dissection

Lost to follow up

Wigger, Stortecky, Most, Englberger 58

F

51 Years

Acupuncture

Acupuncture

None Reported

Left Ventricle

Sternotomy and heart dissection

Stable

Discussion

Self-insertion of needles into the heart, particularly among neuropsychiatric patients, has been frequently reported in the literature, as described above [1-27]. Our patient’s subacute presentation, the apparent needle migration within the ventricle, and the difficulty in obtaining consent, all presented challenging aspects of this particular case. The potential risks of a needle within the heart of pericardium are protean. These include acute or delayed cardiac tamponade, pericarditis, endocarditis, acute thrombus formation, thromboembolism, and recurrent local and systemic infection [22]. The heart may be more vulnerable to serious injury, when the foreign body is extraventricular rather than completely intraventricular per Perotta et al [28]. They posit that the repetitive wall motion of the heart against a fixed foreign body has the potential for bleeding and/or infection with subsequent tamponade. They also suggest that less symptomatic patients or those with delayed presentation and evidence of fibrosed or non-mobile foreign bodies within the cardiac space could possibly be managed conservatively [5].

As far as diagnosis of this pathology, initial patient history and chest plain film should suffice. The patients’ clinical presentation, like in our case, could be delayed, in which asymptomatic patients could suffer sequelae mentioned. We found that in recent reports management of foreign bodies, specifically needles within the heart, still requires a case by case evaluation and treatment. Depending on location and accessibility, endovascular, percutaneous, thoracoscopic, or thoracotomy approaches might be utilized. Alternatively, with any evidence of intracardiac penetration, the safest approach involves sternotomy with or without the use of cardiopulmonary bypass [29-31]. From the literature, there are general guidelines regarding indications for surgical intervention.

Size of needle was not a criteria-determining intervention within the literature reviewed, however, our opinion left ventricular needles should be treated urgently or emergently because of the possibility of embolization to vital structures. Any intracavitary needle regardless of size should be considered for removal. Symptomatic needles (foreign bodies) manifesting with infection, arrhythmia, bleeding, or neurologic findings, should be removed [22]. As Perrota et al concludes in their review, intracardiac needles should be promptly taken for intraoperative removal, especially if the needle is within the myocardium. 

Asymptomatic foreign bodies discovered soon after injury with associated risk of infection, embolization, or erosion should be removed. Asymptomatic foreign bodies demonstrating fibrosis or fixation within the myocardium, pericardium, or pericardial space, may be able to be treated conservatively with some form of serial examination going forward [28,32]. Our results also demonstrate that acupuncture under an unlicensed acupuncturist is not benign.  Our review demonstrates the safety of surgical intervention with favorable and predictable outcomes; it may be the preferred management approach regardless of presentation.

Limitations of our study revolve around the difficulty of drawing conclusions from a vast collection of case reports with varying levels of detail regarding both the presentation and management.

Conclusion

In conclusion, patients with neuropsychiatric illness and history of needle self-insertion, particularly into the cardiac space, invariably produce a challenging treatment problem involving psychosocial, physiologic, and follow-up dilemmas. These patients may be best served with an operative approach for needle extraction.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

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Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

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Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

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Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

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Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

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Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

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Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

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Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

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Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

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Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

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Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

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Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

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Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

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Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

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Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

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Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

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Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

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Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

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Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

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Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

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Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

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Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

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Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

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Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

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Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

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S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

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Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

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George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

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Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

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Khurram Arshad

Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.

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Gomez Barriga Maria Dolores

The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.

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Lin Shaw Chin

Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.

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Maria Dolores Gomez Barriga

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.

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Dr Maria Dolores Gomez Barriga

Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.

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Dr Maria Regina Penchyna Nieto

Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.

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Dr Marcelo Flavio Gomes Jardim Filho

Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”

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Zsuzsanna Bene

Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner

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Dr Susan Weiner

My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.

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Lin-Show Chin

My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.

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Sonila Qirko

My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.

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Luiz Sellmann