A Magic Bullet Through the Heart
Penetrating cardiac trauma caused by gunshot constitutes the most fatal form of cardiothoracic injury because of its potential mortality. The heart lesions encountered in such situations are different and are sometimes surprising.1,2
We report a 16-year-old boy whom a relative accidentally shot at close range while trying to fieldstrip the handgun. The pistol, originally a replica manufactured to fire blank cartridges, was illegally converted by a gunsmith to fire live ammunition. In this case, the high-velocity projectile was a 6-mm brass pellet; it entered the right anterior thoracal cavity approximately 3 cm above the nipple. A noncontrast scan was performed and showed a linear cloud of density in the whole chest, marking the passage of the bullet (Figures 1 and 2⇓).
The patient was put on urgent extracorporeal circulation. The exploration of the surgical field revealed that, after passing through the right lung, the pellet penetrated the right atrium, pierced through the atrial septum, punctured a hole near the posterior leaflet of the mitral annulus, and exited the heart on the left ventricle just near the circumflex artery close to the atrioventricular groove. The pellet then passed through the left lung and ended up between the eighth and ninth ribs. The surgical procedure consisted of cardiac and thoracal entry, and the exit wounds were sutured primarily by prolene sutures supported with Teflon pledgets. Fortunately, the patient did well after surgery and was discharged from the hospital 10 days after treatment. The control echocardiography after 6 months revealed no myocardial abnormalities, no pericardial effusion, and no valve-related problems (Movies I and II). The ECG was unremarkable, with no signs of ischemic or conduction pathologies.
It is important to carefully follow up with patients after gunfire to the heart, because further changes in the valves and related structures are possible.1
The online-only Data Supplement, consisting of movies, is available with this article at http://circ.ahajournals.org/cgi/content/full/115/20/e467/DC1.