Bullet Embolization From the Right Internal Jugular Vein to the Right Ventricle

Abstract

I read with great interest the case report by Soong et al entitled “Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization from the Left Brachiocephalic Vein”.1 We encountered a similar case. A 24-year-old man was transferred to our trauma unit with penetrating injuries. He had gunshot wounds to the posterior aspect of his neck, right shoulder, and right thigh. He was hemodynamically stable, breathing spontaneously, and neurologically intact. X-rays from the referring hospital showed a radioopaque object overlying the cardiac silhouette (Fig 1). Computed tomography (CT), at our institution, of the head and neck showed soft tissue injury of the posterior aspect of the neck, small fragments of radioopaque material scattered from the right scapular tip to around the right carotid sheath, and a hematoma in the right sternocleidomastoid muscle. Chest CT revealed a radioopaque object within the tip of the right ventricle without associated hemothorax or pneumothorax (Fig 2). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) (Fig 3, Fig 4, Fig 5) showed the bullet lodged in the apex of the right ventricle. There was no pericardial effusion, right ventricular wall penetration, or damage to the papillary muscles or tricuspid valve. Cardiovascular surgery opted for conservative management, and he was sent home after an uneventful 6-day stay. He was recovering well one month post-discharge and was lost to further followup.Fig 2CT of the chest.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3TTE—bright echodensity (1cm x 0.7 cm) in the apex of the right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4TEE—four-chamber view showing bright echodense structure in the apex of the right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 5TEE—transgastric view of the right ventricle showing bright echodense structure.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The best therapeutic approach of a stable patient with a bullet embolized to the heart is controversial. Some authors strongly urge immediate exploration,1Soong W. Beckmann A.K. Lin L. et al.Transesophageal echocardiography in the management of right ventricular bullet embolization from the left brachiocephalic vein.J Cardiothorac Vasc Anesth. 2012; 26: 459-461Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 2Howanitz E.P. Murray K.D. Galbraith T.A. et al.Peripheral venous bullet embolization to the heart. Case report and review of the literature.J Vasc Surg. 1988; 8: 55-58Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar while others advocate conservative management.3Gandhi S.K. Marts B.C. Mistry B.M. et al.Selective management of embolized intracardiac missiles.Ann Thorac Surg. 1996; 62: 290-292Abstract Full Text PDF PubMed Scopus (33) Google Scholar Because the bullet was determined to be lodged in the apex of the right ventricle and not resting freely in the cardiac chamber, we decided to treat our patient conservatively. We believe the management should be individualized to each patient. In conclusion, we agree with Soong et al1Soong W. Beckmann A.K. Lin L. et al.Transesophageal echocardiography in the management of right ventricular bullet embolization from the left brachiocephalic vein.J Cardiothorac Vasc Anesth. 2012; 26: 459-461Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar that echocardiography is a useful imaging modality. It was vital in locating the bullet and defining the extent of cardiac trauma to guide treatment in our case.