Directly to the Heart
A 24-year-old male was intentionally shot with a 0.410-caliber rifle to the anterior chest from a distance of about 10 m. The patient did not lose consciousness and was able to seek medical assistance on his own. On presentation, the patient had normal vital signs. A chest x-ray (Figure 1) and thoracoabdominal computed tomographic scan (Figures 2 and 3⇓) were immediately performed and showed multiple metallic foreign bodies, most of them in the anterior chest wall, many in the lung parenchyma, and some within the mediastinum. One pellet was located between the aorta and the superior vena cava. Another was adjacent to the esophagus, at the level of T3, where a small pneumomediastinum was also identified. Most importantly, 2 bullets were also visible within the heart. An echocardiogram was performed that demonstrated the exact localization of one of these bullets in the posterior wall of the heart near the base of the posterolateral papillary muscle (Figures 4 and 5⇓). The patient also underwent an esophagoscopy and a bronchoscopy, both of which were normal. A right pleural effusion was drained with a chest tube. The patient remained stable without any cardiac symptoms or arrhythmias. Against medical advice, he left the hospital 3 days after his admission and was lost at follow-up.
The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/114/13/e515/DC1.