Delayed Presentation of a Retained Intracardiac Metallic Foreign Body Associated with Rupture of the Right Sinus of Valsalva and Anterior Mitral Leaflet Perforation: A Case Report

Abstract

Background: Intracardiac foreign bodies are rare and may remain clinically silent for years, particularly following penetrating or blast-related thoracic trauma. Delayed manifestations can include valvular damage, intracardiac shunting, and heart failure, making diagnosis challenging long after the initial injury. Case Presentation: We report the case of a 37-year-old man who presented with progressive exertional dyspnea, palpitations, and fatigue four years after surviving a bomb blast that caused thoracic trauma requiring surgical intervention. Cardiac examination revealed new murmurs. Transthoracic and transesophageal echocardiography demonstrated rupture of the right sinus of Valsalva with a continuous left-to-right shunt into the right atrium and severe mitral regurgitation due to perforation of the anterior mitral leaflet. A fixed echogenic structure was identified in the inferobasal wall of the left ventricle. Fluoroscopy and cardiac computed tomography confirmed a retained metallic foreign body embedded within the left ventricular myocardium. There was no echocardiographic or laboratory evidence of active infective endocarditis. Results: The patient experienced symptomatic improvement with medical therapy using a loop diuretic and a beta-blocker. Given the coexistence of a significant aorto-atrial shunt, severe mitral regurgitation, and a retained intracardiac foreign body, he was referred for cardiothoracic surgical management, including foreign body extraction and mitral valve repair. However, the patient was lost to follow-up, and surgical outcomes could not be assessed. Conclusion: This case highlights the potential for delayed and complex structural cardiac complications years after blast-related thoracic trauma. In patients with a history of penetrating or blast injury who develop new murmurs or unexplained cardiopulmonary symptoms, a systematic diagnostic approach using echocardiography and targeted cross-sectional imaging is essential for identifying retained foreign bodies and associated structural lesions and for guiding timely management.