Missile in the heart

Abstract

S.S. was a 32-year-old woman who presented witha thoracic gunshot wound. An entrance wound wasnoted over the deltoid region of the left shoulder.On admission, she was haemodynamically stablewith a systolic blood pressure of 100 mmHg and apulse rate of 100/min. The respiratory rate was24 breaths/min. Antero-posterior and lateral chestradiographs,revealedawidenedmediastinumandaretained intrathoracic bullet, located within thecardiac silhouette (Fig. 1 A and B–—due to the poorqualityof the initial mobile chest radiographs, post-operative X-rays are shown). A supine haemothoraxwasalsopresentontheleftside.Angiographyofthemediastinal and greaterthoracicvessels andgastro-grafin swallow was normal. However, the vascularradiologist reported the missile moving with eachheart beat during screening angiography. An ultra-sound of the heart was normal. Urgent echocardio-graphy confirmed the bullet in the inter-atrialseptum. No significant pericardial effusion and/orvalvular or septal defects were detected. Thepatient was prepared for urgent sternotomy. Atsurgery, the pericardial sac contained about 20 mlof blood. A one-centimeter laceration of the rightatrium started bleeding with manipulation and wasrepaired with pledgeted-prolene sutures. The car-diac surgeons proceeded to enter the right atriumvia the atrial appendage. The missile was digitallypalpated and found to be completely embedded inthe atrial wall, not mobile, and considered to beclose to the coronary sinus. It was therefore left insitu. She made an uneventful recovery and wasdischarged6dayslater.Shewasreadmitted2weekslater with left sided pleuritic-type chest pain.Exhaustive investigations excluded endocarditisand reaccummulation of an effusion or atrial walldefects. The pain subsided with non-steroidal anti-inflammatorydrugadministration.Shehasbeenlostto follow-up. A telephonic enquiry, 4 years later,revealed the patient to be alive and well, with nocomplaints.