Management of bullets lodged in the heart

Abstracts

Paciente do sexo masculino, 29 anos, apresentando ferimento por arma de fogo, com projétil alojado no coração e que chegou ao hospital hemodinamicamente estável. O diagnóstico, evidenciando a localização da bala, foi feito pelo ecocardiograma transesofágico (ET). Após 18 dias, foi submetido à cirurgia eletiva, sem circulação extracorpórea (CEC), para retirada do projétil encravado em parede anterior do ventrículo direito (VD) e septo interventricular (SIV), com sucesso. Os autores discutem a conduta terapêutica para os projéteis retidos no coração, com base na literatura consultada, concluindo que a cirurgia para remoção dos mesmos pode ser indicada em pacientes assintomáticos individualizados.

Ferimentos por arma de fogo; Corpos estranhos; Traumatismos cardíacos; Septo cardíaco; Septo cardíaco; Ventrículos cardíacos; Ventrículos cardíacos


A 29-year-old man presented with a bullet lodged in his heart. He arrived at the hospital in a hemodynamically stable condition. The transesophageal echocardiogram performed for diagnosis revealed the location of the bullet. After 18 days, he underwent an elective off-pump cardiac surgery fto remove the bullet from the right ventricle wall and interventricular septum. The postoperative evolution was uneventful. The authors discuss the therapeutic options for removing bullets from thr heart, based on published data. They concluded that some asymptomatic patients with a bullet embedded in the heart should undergo surgery.

Wounds; Wounds; Foreign bodies; Heart injuries; Heart septum; Heart septum; Heart ventricles; Heart ventricles


CASE REPORT

Management of bullets lodged in the heart

Enoch Brandão de Souza Meira; Ruggero Bernardo Guidugli; Daniela Barros de Souza Meira; Ranieri Meirelis Rocha; Mário Cláudio Ghefter; Ivo Richter

Correspondence

ABSTRACT

A 29-year-old man presented with a bullet lodged in his heart. He arrived at the hospital in a hemodynamically stable condition. The transesophageal echocardiogram performed for diagnosis revealed the location of the bullet. After 18 days, he underwent an elective off-pump cardiac surgery fto remove the bullet from the right ventricle wall and interventricular septum. The postoperative evolution was uneventful. The authors discuss the therapeutic options for removing bullets from thr heart, based on published data. They concluded that some asymptomatic patients with a bullet embedded in the heart should undergo surgery.

Descriptors: Wounds, gunshot, surgery. Foreign bodies, surgery. Heart injuries. Heart septum, injuries, surgery. Heart ventricles, injuries, surgery.

INTRODUCTION

Heart injuries by gunshots are more frequent nowadays, due to the increase in violence in big urban centers. The pre-hospitalization mortality rate is normally high and can reach 50%. Victims that manage to arrive in the emergency department almost always need immediate resuscitation and thoracotomy. Some survivors can remain with projectiles embedded in the heart. The treatment of these patients has been the subject of discussion and controversy and the best conduct has not been well-established yet [1].

CASE REPORT

G.P.N, a 29-year-old male Caucasian patient, was admitted to the emergency department of HSPE, referred from another hospital due to a gunshot wound. The bullet passed through his right arm and penetrated the thorax. In the physical exam, he presented with an arterial pressure of 110 x 80 mmHg, a heart rate of 80 beats per minute, with a tubular drain in the right pleural cavity, signs of a fracture of the humerus, with absence of radial and ulnar pulses on the right side. Radiographies showed a supracondylar fracture of the right humerus, tubular drain in the pleural space on the same side and the presence of the projectile superimposed on the cardiovascular silhouette (Figure 1). In virtue of the presence of a right humeral artery lesion, the patient was submitted to emergency surgery for reconstruction using an autologous saphenous vein graft and simultaneously, surgery treatment of the fracture.

He had a good post-operative evolution and after eleven days, a chest radiography showed an unaltered projectile position on the cardiovascular silhouette. The electrocardiogram continued normal, the transesophageal echocardiogram (TE) showed a slight pericardial effusion and the image of a metallic object located in the front wall of the right ventricle (RV) and interventricular septum (IVS) - Figure 2.

After the 11th day, he was submitted to an exploration thoracotomy, by left antero-lateral incision, with drainage of the pericardial liquid, at which time the surgeon verified, by palpation, the presence of a bullet lodged in the RV anterior wall. The surgical team considered the possible risks of its removal without CPB and opted to perform the procedure at another time and transferred the patient to the Cardiovascular Surgery Department.

After seven days, he was submitted at another surgery using median sternotomy and a scar was found in the RV anterior wall near to the anterior interventricular coronary artery. An incision in this area allowed the caliber .38 bullet to be removed (Figure 3), from the interventricular septum. The incision was sutured with individual 4-0 polypropylene stitches, without the necessity of cardiopulmonary bypass. The patient evolved satisfactorily and the immediate and late pos-operative periods were uneventful. The patient is still asymptomatic after six years of clinical follow up.

COMMENTS

Projectiles retained in the heart can be partially or totally embedded in the myocardial or can be found free inside the heart chambers, pericardial cavity, or lodged by the side of the great vessels. They can also arrive in the heart through venous vascular injuries and remain free in the right heart chambers or stay embedded in the RV trabeculae.

The immediate manifestation of bleeding with a build up inside the pericardial sack or pleural space can be slight, as in the case present; however, symptoms of valvar insufficiency, communication defects between the heart chambers and disorders of electric stimulus conduction can occur immediately. Late manifestations include systemic or pulmonary embolization of the projectile, acute myocardial infarction, ventricular aneurism, endocarditis, pericarditis and cardiac neurosis. These complications are related to the type, size, form, localization of the projectile and its relationship to the heart muscle [1].

SYMBAS et al. [1] made a wide-ranging review of published cases, since World War II (1940 to 1988) and reported 201 patients with 222 projectiles retained in the heart (Group 1), together with their personal series of 24 patients (1968 to 1988) - (Group 2). In total, 114 projectiles were removed from the two groups. There were six deaths of patients in Group 1 who had intracavitary, intrapericardial or partially intramyocardial projectiles, the removal of which was not attempted or was unsuccessful. The authors concluded that large projectiles and intrapericardial projectiles and those partially embedded in the heart muscle should be removed and that the completely embedded projectiles in asymptomatic patients do not require intervention. However, complications have been reported in these cases, such as pericarditis, embolization, endocarditis and RV coronary fistulae.

WALES et al. [2] reported a case of a projectile retained in the RV and IVS, where the patient was submitted to surgery after four years due to cardiac arrhythmias and much anxiety. STOLF et al. [3] described their experience with two patients who presented with projectiles lodged in the IVS and were operated on under cardiopulmonary bypasses. Another question that should be mentioned is the possibility of saturnism. Many authors have reported the development of this complication in consequence of the permanence of lead projectiles in the organism over many years [4].

Although the patient remained asymptomatic, we decided to remove the projectile because of its localization in the IVS and the possibility of the aforementioned complications. [2,5]

CONCLUSION

The authors considered that the therapeutic conduct towards retained projectiles in the heart in asymptomatic patients, although this is a controversial subject, can be surgical in specific cases. These cases include those that involve large projectiles, intrapericardial projectiles or those partially embedded in the myocardium, with the aim of preventing possible complications. This conduct is motivated by the diagnostic precision obtained with computed tomography, angiocardiography and principally, pre-operative or intra-operative transesophageal echocardiography and by the low surgical risk, considering the possibilities that cardiovascular surgery offers nowadays, in the intra-operative management of the heart, in off-pump procedures and with the development of heart stabilizers [6].

BIBLIOGRAPHIC REFERENCES

Article received in November, 2004

Article accepted in February, 2005

Work performed in the Hospital do Servidor Público Estadual, Francisco Morato de Oliveira (HSPE)

  • 1. Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles. A review of the literature and personal experience. Ann Surg. 1990;211(5):639-48.
  • 2. Wales L, Jenkins DP, Smith PL. Delayed presentation of right ventricular bullet embolus. Ann Thorac Surg. 2001;72(2):619-20.
  • 3. Stolf NA, Fernandes PM, Pomerantzeff PM, Dallan LA, Camarano GP, Jatene AD. Bullet in the interventricular septum: report of surgical removal in two cases. Thorac Cardiovascular Surg. 1988;36(1):51-3.
  • 4. Stromberg BV. Symptomatic lead toxicity secondary to retained shotgun pellets: case report. J Trauma. 1990;30(3):356-7.
  • 5. Stolf NA, Pomerantzeff PM, Pego-Fernandes PM, Medeiros CC, Fontes RD, Machado LA et al. Projétil de arma de fogo no septo interventricular. Relato de caso. Arq Bras Cardiol. 1987;49(4):241-4.
  • 6. Fedalen PA, Frank AM, Piacentino III V, Fisher CA, Pathak AS, Furukawa S et al. Off-pump extraction of an embedded high posterior left ventricular bullet utilizing a new cardiac stabilization device. J Trauma. 2001;51:1011-3.

  • Correspondence to
    Enoch Brandão de Souza Meira. Rua Itapeva,
    490, 11º andar, cj. 113. São Paulo, SP, Brasil. CEP 01332-000. Tel
    (55) 11 288 5020 / Fax (55) 11 3283 1571.
    E-mail:

Publication Dates

  • Publication in this collection
    11 Sept 2007
  • Date of issue
    Mar 2005

History

  • Received
    Dec 2004
  • Accepted
    Feb 2005
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