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Khorgami M, Khalaj F, Gholampour M, Tatari H. Missile embolism from pulmonary vein to left ventricle: report of a case. Front Cardiovasc Med 2024; 11:1342146. [PMID: 38464844 PMCID: PMC10920231 DOI: 10.3389/fcvm.2024.1342146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 01/22/2024] [Indexed: 03/12/2024] Open
Abstract
Missile embolization is rare in penetrating trauma, occurring in 0.3% of cases. Bullet embolism into the left ventricle is less frequent, with few instances described in the literature. This paper describes an instance of left ventricular bullet embolism from the pulmonary venous system following gunshot chest trauma. A 7-year-old boy sustained a gunshot wound to his chest during an assault accident. Despite thoracic pain, he remained conscious and exhibited vital signs. A CXR and CT scan revealed a bullet in the left mediastinum. A left thoracotomy was performed to remove blood and clots from the pericardium. The patient was sent to a tertiary referral hospital for further investigation. The patient underwent elective surgery to remove the foreign body from inside the heart. The procedure involved a partial thymectomy and pericardial opening, and the patient was released from medical care after 14 days. After 6 months, there were no signs or symptoms of cardiothoracic infection or evidence of mitral valve regurgitation in echocardiography.
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Affiliation(s)
- Mohammadrafie Khorgami
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Fattaneh Khalaj
- Liver and Pancreatobiliary Diseases Research Center, Digestive Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maziar Gholampour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Tatari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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2
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Janus SE, Hajjari J, Chami T, Sabik E. Left Ventricular Gunshot Injury With Migration to the Aorta Causing Severe Aortic Insufficiency. J Cardiothorac Vasc Anesth 2021; 36:2041-2045. [PMID: 34030959 DOI: 10.1053/j.jvca.2021.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/14/2021] [Accepted: 04/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Scott E Janus
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH.
| | - Jamal Hajjari
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Tarek Chami
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH
| | - Ellen Sabik
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, OH
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3
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The Use of Transesophageal Echocardiography in the Diagnosis and Management of an Intracardiac Missile Embolism. A A Pract 2020; 14:e01326. [DOI: 10.1213/xaa.0000000000001326] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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4
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Goeddel LA, Fraser CD, Daly RJ, Sciortino CM, Sheinberg RB. A Bullet in the Aortic Root: Utility of Transesophageal Echocardiography in Penetrating Thoracic Trauma. Anesth Analg 2020; 129:e69-e72. [PMID: 31425202 DOI: 10.1213/ane.0000000000002440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Lee A Goeddel
- From the Department of Anesthesiology and Critical Care Medicine
| | - Charles D Fraser
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Rodrigo J Daly
- From the Department of Anesthesiology and Critical Care Medicine
| | - Christopher M Sciortino
- Division of Cardiac Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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5
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Francescon D, Mehta M, Kosier A, Reily R, Boulger C, Prats M, Bahner D. Chest Pain and Dyspnea With a Piercing Diagnosis. Chest 2019; 156:e37-e39. [PMID: 31395266 DOI: 10.1016/j.chest.2019.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/16/2019] [Accepted: 03/25/2019] [Indexed: 11/29/2022] Open
Affiliation(s)
- Daniel Francescon
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Milap Mehta
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Austin Kosier
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Robert Reily
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Creagh Boulger
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Prats
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - David Bahner
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
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6
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Alan Elison RM, Jose Antonio DE, Hector SM, Dolores LG, Francisco Xavier TG. Surgical management of late bullet embolization from the abdomen to the right ventricle: Case report. Int J Surg Case Rep 2017; 39:317-320. [PMID: 28898794 PMCID: PMC5602822 DOI: 10.1016/j.ijscr.2017.08.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 08/29/2017] [Accepted: 08/30/2017] [Indexed: 11/17/2022] Open
Abstract
We present the case of a late bullet migration. We describe our surgical approach for a bullet extraction. We review the literature on the different treatment options in patients with bullet migration.
Introduction Secondary embolus from gun projectile is a rare entity, it represents a clinical and therapeutic dilemma because the potential complications involving central and peripheral circulation. Each case reported in the literature represents a challenge because their unique and different clinical scenarios. Presentation of case We present the management of a 33-year-old man with past history of a gunshot wound on left flank with no evidence of any exit wounds, treated with exploratory laparotomy without removing the gunshot bullet from the abdomen. The patient presents 6 years later with non-productive cough and retrosternal pain with no other symptoms; the patient underwent a chest x-ray, electrocardiogram, thoracoabdominal CT, echocardiogram and cardiac catheterization and showed a bullet in the right ventricular floor. The projectile was extracted by sternotomy with extracorporeal circulation through the right atrium, without any complications. Discussion In 1834, Thomas David reported for the first time a wood-fragment embolization. There have been reported less than 200 cases including embolization of other materials; most of the gunshot bullet embolization cases reported on literature were reported after war. Clinical manifestations are associated with the anatomical site of embolism and mortality rate for a retained bullet is 6% associated with complication in 25% of cases. Mortality rate decreases to 1–2% if the bullet is removed. Conclusion There are no established guidelines about the management of migrating foreign bodies or bullets, however, conservative, endovascular and surgical management have been proposed. In the cases of bullet embolization to the thoracic cavity, surgery represents a safe, low risk approach with high success rates.
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Affiliation(s)
- Ramos Mayo Alan Elison
- Escuela de Medicina, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Avenida Morones Prieto 3000, Colonia Los Doctores, CP 64710, Mexico.
| | - Diaz Elizondo Jose Antonio
- Escuela de Medicina, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Avenida Morones Prieto 3000, Colonia Los Doctores, CP 64710, Mexico
| | - Segura Marin Hector
- Escuela de Medicina, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Avenida Morones Prieto 3000, Colonia Los Doctores, CP 64710, Mexico
| | - Lopez Garnica Dolores
- Escuela de Medicina, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Avenida Morones Prieto 3000, Colonia Los Doctores, CP 64710, Mexico
| | - Treviño Garza Francisco Xavier
- Escuela de Medicina, Instituto Tecnologico y de Estudios Superiores de Monterrey, Monterrey, Avenida Morones Prieto 3000, Colonia Los Doctores, CP 64710, Mexico
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Ghanaat M, Goldenberg C, Walsh J, Sclafani SJ. Endovascular management of an intracardiac bullet. Injury 2015; 46:166-8. [PMID: 25245664 DOI: 10.1016/j.injury.2014.07.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2014] [Accepted: 07/19/2014] [Indexed: 02/02/2023]
Abstract
Intravascular bullets may cause diagnostic and management difficulties. We describe a bullet overlying the cardiac silhouette on X-ray which was identified to be at the cavoatrial junction on cavography. The bullet was removed via endovascular techniques utilizing occlusion balloon and reverse trendelenberg position.
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Affiliation(s)
- Mahyar Ghanaat
- SUNY Downstate Medical Center, Department of Interventional Radiology, United States.
| | - Charles Goldenberg
- SUNY Downstate Medical Center, Department of Interventional Radiology, United States
| | - James Walsh
- SUNY Downstate Medical Center, Department of Interventional Radiology, United States
| | - Salvatore J Sclafani
- SUNY Downstate Medical Center, Department of Interventional Radiology, United States
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Abstract
Management of the metallic foreign body in the heart remains controversial. Evaluation of possible methods for this issue and its possible treatments are discussed, the results of which may lead to a more effective strategy for management of intracardiac foreign bodies.
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Affiliation(s)
- Xiaoweng Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
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9
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Soong W, Beckmann AK, Lin L, Ahmad US, McGee EC. Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization From the Left Brachiocephalic Vein. J Cardiothorac Vasc Anesth 2012; 26:459-61. [DOI: 10.1053/j.jvca.2011.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Indexed: 11/11/2022]
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10
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Lundy JB, Johnson EK, Seery JM, Pham T, Frizzi JD, Chasen AB. Conservative management of retained cardiac missiles: case report and literature review. JOURNAL OF SURGICAL EDUCATION 2009; 66:228-235. [PMID: 19896630 DOI: 10.1016/j.jsurg.2009.04.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Revised: 04/06/2009] [Accepted: 04/10/2009] [Indexed: 05/28/2023]
Abstract
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.
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Affiliation(s)
- Jonathan B Lundy
- Department of Trauma/Surgical Critical Care, Brooke Army Medical Center, Fort Sam Houston, Texas, USA.
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11
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Filgueiras-Rama D, Moreno-Yanguela M, Ruiz-Cantador J, Martín-Reyes R, Navas-Lobato MA, López-Sendón JL. A lucky cardiac shotgun? Eur Heart J Cardiovasc Imaging 2009; 10:462-3. [DOI: 10.1093/ejechocard/jen327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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12
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Galante J, London JA. Left ventricular bullet embolus: a case report and review of the literature. J Emerg Med 2008; 39:25-31. [PMID: 18614325 DOI: 10.1016/j.jemermed.2007.09.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2007] [Accepted: 09/13/2007] [Indexed: 11/29/2022]
Abstract
Missile embolization to the heart occurs infrequently in penetrating trauma. The lack of a concentrated experience at any single institution contributes to the controversies pertaining to diagnostic and therapeutic approaches to management. The objective of this study was to describe a case of a left ventricular bullet embolus and provide a detailed diagnostic and therapeutic framework for management of intracardiac projectiles. Initial management of a patient with suspected intracardiac projectiles is dictated by his or her hemodynamic status. Unstable patients generally require operative intervention. In the stable patient, associated injuries must be sought. Localization of the projectile can be aided by echocardiogram, fluoroscopy, or angiography. Definitive management is individualized, and can range from observation to percutaneous or operative extraction. The decision depends on the cardiac chamber involved, the patients' symptoms, and the projectile's size, shape, and location within the chamber. Missile embolus to the heart is an infrequent occurrence, but when found presents a diagnostic and therapeutic challenge. Management strategies should be individualized. A detailed management algorithm is provided.
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Affiliation(s)
- Joseph Galante
- Department of Surgery, University of California, Davis, Sacramento, California 95817, USA
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Pons F, Lang-Lazdunski L, de Kerangal X, Chapuis O, Bonnet PM, Jancovici R. The role of videothoracoscopy in management of precordial thoracic penetrating injuries. Eur J Cardiothorac Surg 2002; 22:7-12. [PMID: 12103365 DOI: 10.1016/s1010-7940(02)00248-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES To report on the value of diagnostic videothoracoscopy in patients with possible penetrating cardiac wounds. METHODS Thirteen patients admitted over a 4 year period with hemodynamic stability and a penetrating injury in cardiac proximity had exploratory videothoracoscopy. All data related to those patients were retrospectively reviewed. RESULTS Eighty-five percent of patients had videothoracoscopy within 8 h of trauma. In most cases (eight of 13), operations were performed on patients in the supine position with the chest slightly rotated. Nine patients had a left hemothorax, five had pulmonary lacerations and five had a bleeding parietal vessel. Pericardial exploration was achieved either by direct vision (nine patients), or by the performance of a pericardial window (four patients). Acute hemopericardium related to a cardiac wound was diagnosed in two patients. Procedures included evacuation of clotted hemothorax (six patients), stapling of pulmonary laceration (four patients), and electrocoagulation of bleeding parietal vessel (four patients). Four patients required conversion to thoracotomy: two for repair of a cardiac wound, one for adequate exposure of the pericardium and one for ligation of a bleeding intercostal artery. The mean operative time was 37+/-23 min. Two patients experienced postoperative complications (coagulopathy, subcutaneous emphysema) and the in-hospital mortality was 0%. The mean hospital stay was 10+/-4 days. CONCLUSIONS In the hands of an experienced surgeon, videothoracoscopy may represent a valid alternative to subxiphoid pericardial window in patients with hemodynamic stability and a suspected cardiac wound. Videothoracoscopy can rule out a cardiac injury and allows for the performance of associated procedures such as diaphragm assessment/repair, evacuation of clotted hemothorax, hemostasis of parietal vessels or pulmonary laceration and removal of projectiles.
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Affiliation(s)
- F Pons
- Department of Thoracic and General Surgery, Percy Military Hospital, Clamart, France.
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Cánoves J, Mainar L, Chorro FJ, Gimeno V, Bodí V, Egea S, Porres JC, López Merino V. [The assessment of cardiac involvement in a case of a thoracic injury from a firearm]. Rev Esp Cardiol 1997; 50:729-32. [PMID: 9417564 DOI: 10.1016/s0300-8932(97)73290-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
We report the case of a patient with a gunshot wound in the chest with a multiple small-caliber intrathoracic projectiles. The different noninvasive techniques employed to evaluate the anatomical location of these projectiles are discussed, together with their cardiac structural repercussions. The data provided by a simple chest X-ray, Computed Tomography (CT) and transthoracic echocardiography are commented on. A simple chest X-ray was unable to discern the location of the projectiles, in contrast to CT, which was able to identify both the number of projectiles and their location. The information provided was enhanced by transthoracic echocardiography, particularly in relation to those projectiles situated in anterior cardiac regions.
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Affiliation(s)
- J Cánoves
- Servicio de Cardiología, Hospital Clínico Universitario, Valencia
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Nishioka T, Fontana G, Luo H, Berglund H, Kim CJ, Fishbein MC, Siegel RJ. Intracardiac thrombus formation associated with a nonpenetrating gunshot wound of the right ventricular outflow tract demonstrated by transesophageal echocardiography. Am Heart J 1996; 132:1265-7. [PMID: 8969579 DOI: 10.1016/s0002-8703(96)90471-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- T Nishioka
- Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Abstract
TEE has been used in the past 13 years to examine the heart and thoracic aorta, and recently the clinical utility of TEE has greatly expanded to include its use in a variety of thoracic trauma injuries. We retrospectively reviewed the use of TEE in our institution from June 1994 to June 1995. Sixteen patients underwent TEE for a variety of indications, including traumatic aortic dissection, penetrating wounds to the precordium, retrieval of a foreign body, valvular trauma, and postoperative evaluation of cardiac repair. TEE affected patient treatment decisions in all of these cases. As a diagnostic modality and as a guide to specific therapy, TEE was safe, expedient, accurate, and highly valuable in the evaluation of patients with trauma to the heart or great vessels.
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Affiliation(s)
- M Mollod
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA 30303, USA
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