Inspired by Llamas Fuentes et al Med Clin (Barc) 2019.[1]
We have another case report of a serious adverse event following acupuncture. This time cardiac damage from needling in the area of the sternum. But my title refers more to my disappointment at the entire lack of detail for us (the acupuncture profession) to learn anything from the case. The publication is not open access, and there is no abstract on PubMed or on the journal website. My go to colleague for papers did not have access, so I emailed the corresponding author, who quickly replied with a corrected proof version of the paper – a journal letter. The corresponding (second) author is listed working in the UK, so I did not use Google translate to send my request in Spanish, but I can recommend this technique when approaching authors who publish in languages other than English – send your request in both languages, it is likely to be much more convenient for the author, and you may get a quicker reply.
This is a short letter, and there is only just over a paragraph on the case itself. No doubt the journal has limitations on word count and references, and as the authors are emergency physicians, they naturally concentrate on the detail that is relevant to their speciality. I have reproduced the relevant section of the letter below including the original spelling irregularities.
We report a case of a 58-year-old female patient with previous history of hypersplenism and thrombocytemia on treatment with iron replacement therapy and aspirin that presents to the emergency department (ED) with dyspnoea, epigastric and chest pain. The patient has had previously acupuncture treatment consisting in the insertion of three sternal needles before admission to ED. On arrival, the patient was haemodynamically unstable with blood pressure of 70/50mmHg, tachycardic 130bpm, tachypnoea 22rpm and GCS of 13 (E3V4M6). On physical examination, jugular veins were distended. ECG demonstrated sinus tachycardia and electrical alternans. Chest X ray showed cardiomegaly and vascular redistribution, point-of-care-ultrasound (POCUS) demonstrated a pericardial effusion with diastolic collapse of the right ventricle. The patient was transferred to the reference Hospital.
Direct quote from Llamas Fuentes et al.[1]
At arrival, a contrast CT was requested that demonstrated severe pericardial effusion (suspected haemopericardium). The patient was taken immediately to the operating theatre. A small but actively bleeding perforation of the right ventricle was found and successfully closed. The patient had a complete recovery after the operation.”
Direct quote from Llamas Fuentes et al.[1]
Three sternal needles!
Later in the text the authors tell us:
The distance from the surface of the skin to the anterior surface of heart has been estimated to be about 13–19mm.
Direct quote from Llamas Fuentes et al.[1]
And that:
acupuncture needles… are 30mm in length.
Direct quote from Llamas Fuentes et al.[1]
I would be interested to find out where that text came from, since the figures come from the infamous case published in the Lancet in 1995,[2] but the authors do not reference this paper, and neither do the reviews cited. Another interesting detail is that Halvorsen et al say this:
The distance from the skin to the posterior surface of the sternum was estimated at 13-19mm.
Direct quote from Halvorsen et al.[2]
To add to the intrigue, I do not think these figures are published in any other paper, but they have appeared in the Foundation Course quiz since I first wrote it around 20 years ago. Question 3 of the quiz reads as follows:
What is the shortest estimated distance from the skin to the surface of the heart in the adult?
A 13 to 19 mm
B 19 to 25 mm
C 25 to 31 mm
If the detail has found its way from our Foundation Course out into the big wide world, then all the better, but it is somewhat disappointing that the main drive to ensure safe practice has not spread as well, since the authors also assert that:
the vast majority of acupuncturists… consider acupuncture as a totally innocuous procedure.
Direct quote from Llamas Fuentes et al.[1]
Towards the end of the short piece they go on to proclaim (despite uncorrected grammar):
Even in the hand of experience practitioners although the risks are low, they can outweigh the benefits, which are close to zero.
Direct quote from Llamas Fuentes et al.[1]
the benefits… are close to zero!
Ooh harsh, even if understandable from the perspective of an emergency physician dealing with cardiac tamponade.
Well that makes 15 primary reports of cardiac injury I believe. This letter claims 8 prior cases, but references a review from 2013 that only lists 5 because of searching a limited time window – I don’t quite understand why you would time-limit your search for case reports of adverse events.[3] Adrian White was closer when he wrote his landmark safety paper in 2004.[4] He listed 9 primary reports of cardiac injury. It looks as though I need to update my safety & side-effects chapter again, as I still only have a figure of 10. In my defence I was hoping never to have to update this figure in the modern era :-(.
I have written to the authors to request a little more detail, and I have been informed that the doctor who performed the acupuncture recognised immediately that there was a problem and accompanied the patient to hospital. I will update this piece if anything else comes to light.
My guess, and there is little to go on, is that the practitioner missed the midline when needling CV17, and slipped between maybe the 4th and 5th ribs on the left of the lower sternum. Of course, if the needle had been angled obliquely upwards it would have been unlikely to get between the ribs at this point as the gaps are quite narrow close to the sternum. We have noted the risk of certain traditional acupuncture points over the rib cage in a previous publication,[5] since these points all lie in the palpable interspaces between ribs. From my perspective the practice of teaching and using these points needs to stop in favour of safer anatomical approaches.
References
1 Llamas Fuentes R, Valle Alonso J, Turegano Cisneros JM. Cardiac tamponade and right ventricle perforation after an acupuncture procedure. Med Clin (Barc) Published Online First: 22 February 2019. doi:10.1016/j.medcli.2019.01.003
2 Halvorsen TBB, Anda SSS, Naess ABB, et al. Fatal cardiac tamponade after acupuncture through congenital sternal foramen. Lancet 1995;345:1175. doi:10.1016/S0140-6736(95)91004-2
3 Xu S, Wang L, Cooper E, et al. Adverse events of acupuncture: a systematic review of case reports. Evid Based Complement Alternat Med 2013;2013:581203. doi:10.1155/2013/581203
4 White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med 2004;22:122–33. doi:10.1136/aim.22.3.122
5 Peuker E, Cummings M. Anatomy for the acupuncturist – facts & fiction 2: The chest, abdomen, and back. Acupunct Med 2003;21:72–9.
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