Preoperative localization of an intracardiac foreign body by two-dimensional echocardiography

Surgical removal of a bullet in the heart through a trans-mitral approach: a case report

Background

Retained cardiac missiles have been considered bullets, shrapnel, or pellets included in the heart or the pericardial sac. In asymptomatic patients with retained cardiac missiles, the role of surgery is still debated.

Case summary

We describe the case of successful surgical treatment of a retained missile localized within the left ventricle in close proximity of the posterior mitral leaflet. The operation was performed through a transatrial approach, detaching the posterior mitral leaflet. The post-operative course was uneventful. The patient was discharged on the seventh post-operative day. At 30-day follow-up visit, the patient was in good conditions, with normal mitral valve function.

Discussion

The management of retained cardiac missiles should be individualized. If a decision is made to operate, multiple imaging techniques including echocardiography and computed tomography scan are mandatory to precisely locate the bullet.

Retrieval of a Dislodged Catheter Using Combined Fluoroscopy and Intracardiac Echocardiography

This report details a method of percutaneous, transluminal retrieval of an intracardiac foreign body using fluoroscopy in combination with intracardiac echocardiography. During retrieval, intracardiac echocardiography (ICE) provided real-time anatomic localization of a constantly moving, almost radiolucent micropuncture coaxial dilator fragment with respect to the tricuspid and pulmonary valves. This method may serve as a crucial aid in retrieval of intracardiac foreign bodies that are difficult to see with fluoroscopy and which may be adjacent to cardiac valves.

Conservative management of retained cardiac missiles: case report and literature review

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature

OBJECTIVE

Our experience with posttraumatic and iatrogenic foreign bodies in the heart is presented and discussed along with a review of the literature on this subject.

SUMMARY BACKGROUND DATA

Posttraumatic or iatrogenic foreign bodies in the heart can be treated either conservatively or surgically. Controversy exists about optimal management.

METHODS

Fourteen cases of posttraumatic or iatrogenic foreign bodies in the heart observed between 1955 and 2000 were studied. Our series includes the following: bullets into the right or left ventricle (4 cases); needles in the left ventricle, atrium, and pulmonary artery (3 cases); retained catheter fragments in the right ventricle, right atrium, or in the pulmonary artery (4 cases); a grenade fragment into the right atrium (1 case); a circular saw fragment into the right ventricle (1 case); and a commissurotomy ring into the left atrium (1 case).

RESULTS

Foreign bodies were removed when in the cardiac cavities (1 case); when in the presence of associated risk factors like embolism, arrhythmia, or infection (3 cases); and when in the presence of associated signs or symptoms including cardiac tamponade (2 cases), arrhythmia (1 case), fever (2 cases), or anxiety (1 case). Removal was accomplished by a thoracotomy (7 cases) or sternotomy (2 cases), with (3 cases) or without cardiopulmonary bypass, or percutaneously (1 case). Four asymptomatic patients were conservatively treated and have no evidence of complications at a median follow-up of 20 years.

CONCLUSIONS

The management of foreign bodies in the heart should be individualized: (1) symptomatic foreign bodies should be removed irrespective of their location; (2) asymptomatic foreign bodies diagnosed immediately after the injury with associated risk factors should be removed; (3) asymptomatic foreign bodies without associated risks factors or diagnosed late after the injury may be treated conservatively, particularly if they are completely embedded in the myocardium or in the pericardium.

Recurrent pericardial effusion due to gunshot wound of the heart in a hemodynamically stable child--a case report

A 12-year-old girl presented with recurrent pericardial effusion due to firearm pellet injury to the left ventricle. The pellet was localized by two-dimensional echocardiography within the left ventricular apical wall. Since the patient was asymptomatic, left ventriculotomy was avoided to extract the pellet and only pericardial tube drainage was carried out. A slightly elevated blood lead level of the patient was alarming for potential subsequent lead poisoning due to retained pellets.

Management of BB shot wounds to the heart

OBJECTIVE

The aim of this study was to review our experience with BB shot injuries to the heart.

DESIGN

This is a retrospective chart review.

MATERIALS AND METHODS

Three patients were found to have BB injuries to the heart. All patients were stable upon presentation. Echocardiography localized the BB pellets to the muscular septum.

MEASUREMENTS AND MAIN RESULTS

All patients were treated with nonoperative therapy. There was not mortality. One patient developed an interventricular conduction delay that resolved before discharge.

CONCLUSIONS

Nonoperative management of stable patients who present with BB wounds to the heart is safe and effective if the BB is intramuscular. An echocardiogram should be used to localize the pellets and evaluate the pericardium.

Needle injury to the heart

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