ARTICLE IN PRESS
International Journal of Surgery (2006)
www.int-journal-surgery.com
SHORT REPORT
RO
OF
Cardiac bullet embolus after thoracic vena
cava penetrating injury causing tricuspid
valve insufficiency
DP
~o Ettinger, Carlos Hohlenwerger, Paulo Vicente*, Ricardo Eloi,
Joa
Leandro Leite, Paulo Amaral, Edvaldo Fahel
TE
Maranha~o Street, #206, Apartment 102, Pituba, 41830260 Salvador, Bahia, Brazil
KEYWORDS
EC
Bullet;
Embolus;
Heart
RR
Introduction
CO
Emboli of foreign bodies to the heart, although
unusual, have been reported with increasing frequency since 1834 when Davis published the first
case report of a bullet embolus.1 Although bullets
are one of the more common foreign body emboli
to the heart and beyond, a cardiac ballistic embolus
is a very rare situation.2 In the literature very few reports were found, so far this is a unique case, because the patient had a very dangerous lesion
which is the vena cava wound associated with a cardiac embolus causing tricuspid valve insufficiency.
Case report
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A 25-year-old patient was admitted with a history
of armed robbery, having been shot with a 38* Corresponding author. Tel.: þ55 71 33450887.
E-mail address: [email protected] (P. Vicente).
caliber revolver and presenting a gunshot wound in
the right hemithorax. He entered the emergence
room (ER) and physical examination revealed
pervious airways with spontaneous breathing, stable hemodynamically, neurologically normal, with
a penetrating injury above the right clavicle. No
wound exit was noted. The PA and lateral chest
X-ray showed a small hemothorax and a 38-mm
special projectile (low velocity bullet) in the projection of the heart (Fig. 4) After that, a chest
drain was placed and the patient suddenly developed a continuous bleeding via thoracostomy
tube and was taken immediately to the operation
room (OR) to be submitted to a right thoracotomy,
which showed a hemothorax and a bullet entrance
orifice in the superior vena cava. The bullet was
not found and there was not an exit orifice for
the projectile, the injury was treated with a 3-0
polypropylene running suture and closed thoracic
drainage. Later, the patient was stabilized and immediately taken to the intensive care unit (ICU).
1743-9191/$ - see front matter ª 2006 Surgical Associates Ltd. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijsu.2006.04.008
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ARTICLE IN PRESS
2
RO
right atriotomy incision was performed and the
missile was successfully removed from the trabeculae of the right ventricle (Figs. 1 and 2). There
was no evidence of injury to the internal structures
of the heart. The postoperative course was without
complications, and the patient was discharged on
the 5th postoperative day (Fig. 3).
Discussion
TE
After clinical improvement, the surgical and intensive care team looked for the projectile and the
image of the bullet was found in the topography
of the heart. The lateral chest X-ray showed a defocused bullet (characteristic of a cardiac embolus) so the team agreed that the bullet was
moving because it was inside the cardiac chamber.
A systolic murmur was also found, an echocardiography was preceded and the cardiologist found it
normal; a radioscopy was done and the missile
was found moving together with the heart so another echocardiogram was performed by the same
cardiologist and at that time a tricuspid valve insufficiency and an image suggestive of a projectile inside the right ventricle were found. The surgical
team discussed the possibility of percutaneous
transvenous retrieval of the projectile, and the
cardiothoracic team discarded this possibility because of the probable difficulty in assessing the bullet surrounded by the trabeculae of the right
ventricle. The patient was prepared and submitted
to a cardiac surgery; a median sternotomy with cardiopulmonary bypass and bicaval cannulation. A
Figure 3 Patient at the ICU after the operation for the
bullet retrieve.
DP
Figure 1 The 38 special bullet trapped in the chordae
tendineae of the right ventricle, the uninjured tricuspid
valve is also seen after the atriotomy with cardiopulmonary bypass.
OF
Area of bullet entry
The diagnosis of bullet emboli to the heart is
usually not difficult when proper roentgenograms
are obtained. The presence of a wound of entry,
the lack of a wound of exit, and the absence of the
bullet in the wounded part raise the index of
suspicious.2 It is important the attention while analyzing the Chest radiograph and observe the position of the projectile. If the bullet is blurred
(defocused), it indicates the missile is moving
together with the cardiac motion, and can lead
to diagnose a cardiac embolus (Fig. 4A). Extremely
critical patients requiring operative intervention
prior to any X-Rays may have the diagnosis missed
initially, but subsequent films will result in the discovery of the embolized missile,2 as happened in
this case. It is imperative to make an echocardiography to document bullet localization in the right
ventricular cavity prior to surgical removal.3
The classical indications for the surgical removal of cardiac foreign bodies include preventing
embolus of the foreign body to more dangerous
sites, reducing the danger of bacterial endocarditis, preventing recurrent pericardial effusions,
preventing erosion of cardiac wall and diminishing
the incidence of myocardial damage.4 The presence of lead missiles in the cardiovascular system
also may lead to lead toxicity (plumbism).5
Management of bullet embolization to heart can
be treated conservatively in some patients. In this
EC
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J. Ettinger et al.
Figure 2
Retrieve of the projectile.
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ARTICLE IN PRESS
Cardiac bullet embolus causing tricuspid valve insufficiency
Bullet thoracic entry
Superior vena cava
injury
Drain
Right ventricule
OF
Right atrium
RO
Tricuspid valve
DP
A
Bullet
B
Figure 4 (A) Postero-anterior chest X-ray showing blurred bullet in the projection of the right ventricle. (B) Bullet
trajectory.
evaluation and treatment are essential in these
cases.
TE
case, we decided to retrieve the bullet due to the
classical indications and because it was causing
tricuspid insufficiency as shown by the echocardiogram (probably the bullet was pulling the chordae
tendinae and causing this dysfunction). Missiles
that are embedded in the subvalvar apparatus may
require open excision to prevent systemic thromboembolism or chronic valvular dysfunction.6 Another issue to be considered is the possibility of
the patient developing psychological problems related to the awareness that the bullet is inside the
heart, causing ‘‘cardiac neurosis’’.7
There are in medical literature references of
successful percutaneous retrieve of bullet embolus localized in the right ventricle, however, in
our case this was not possible due to the probable
difficulty in assessing the bullet surrounded by
the trabeculae of the right ventricle and due to
the indication of mandatory retrieve previously
cited.
We conclude that a superior vena cava injury
due to gunshot wound associated with a cardiac
embolus is a challenging injury and the specialized
References
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3
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