Bullets retained within the heart: diagnosis and management in three cases.

Abstract

Three cases of gunshot wounds of the chest are reported, in each of which a bullet was retained within the heart. Although it is rare, the surgeon should consider this possibility if the missile overlies the cardiac silhouette on the plain chest radiograph. Fluoroscopy played an important part in confirming the diagnosis. Cardiopulmonary bypass was used in all cases and provides operating circumstances that improve the prospects of success.Despite the increasing number of casualties resulting from penetrating chest injuries, retained foreign bodies inside a cardiac chamber are very rare in civilian life. Among the few reports referring to intracardiac bullets or shell fragments,' -9 the most interesting and important experience was published by Harken,1 2 based on his second world war experience. More recently, with the increasing sophistication of civilian weapons and in particular their increased calibre and muzzle velocity, a cardiac injury produced by such devices often causes extensive damage and the bullet usually passes right through the heart. Nevertheless, there is always the possibility, depending on the circumstances, that a bullet or a fragment has remained inside the heart. Three cases are described here, in each of which a bullet fired from a low velocity gun lay completely free inside a ventricular cavity after penetrating the muscular cardiac wall. She was immediately taken to the operating theatre and the chest was opened by a median sternotomy. After the pericardium had been opened and clot removed cardiac function improved immediately. Since a bullet was known to be within the heart, cardiopulmonary bypass was instituted and the ascending aorta and the superior and inferior venae cavae were cannulated. The aorta was clamped and a cold cardioplegia solution was infused through the ascending aorta. A small perforation was identified on the right ventricular outflow tract. The right ventricle was opened through a small transverse incision and inspection showed that the bullet had also perforated the interventricular septum. The left atrium was opened and a tear in its posterior wall was exposed. The bullet was identified in and removed from the left ventricular cavity, which was inspected through the mitral valve. After the right ventricle, the left atrium, and the interventricular septum had been repaired cardiopulmonary bypass was withdrawn. The patient had an uneventful recovery and was discharged from hospital on the 10th postoperative day. Twenty months later she is leading a normal life.

Left Ventricular Bullet Embolus: A Case Report and Review of the Literature

“…TEE does have limited views of the cardiac apex, which in our case did not allow distinction between an intracardiac vs. intrapericardial bullet. When echocardiography is unable to accurately determine the location of the bullet, fluoroscopy may be helpful (17,18). The motion of pericardial and intracavitary projectiles differ, which usually allows for a clear distinction.…”

Myocardial ischemia caused by external compression of a shotgun bullet

“…Cardiac injuries resulting from shotgun bullets may be life-threatening and are often fatal (1). People who sustain a bullet injury to the myocardium repeatedly do not have a chance to receive medical or surgical treatment.…”