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Bullet embolus to the right ventricle
Bullet Embolus to the Right Ventricle Report of Three Cases JEREMY R. MORTON, MD, Houston, Texas GEORGE J. REUL, MD, Houston, Texas NEAL R. ARBEGAST, MD, Houston, Texas J. EDWARD OKIES, MD, Houston, Texas ARTHUR C. BEALL, Jr, MD, Houston, Texas
In the past the entry of bullets and other missiles into the circulation with subsequent embolization was encountered almost exclusively in battle casualties. More recently, however, with the greater private use of firearms, an increasing number of these injuries are being seen in civilian hospitals. In these cases a variety of different migratory pathways are possible, depending on the site of entry of the missile into the vascular system and the subsequent effects of blood flow and gravity. In reviews of this subject, Straus [I] in 1942 and Harken and Williams [2] in 1946 described a total of forty-five cases of embolic foreign bodies, nine of which represented missiles entering the systemic venous system peripherally and migrating to the right ventricle. During the last four years, we have encountered three cases in which missiles entered the venous system in the lower part of the abdomen and embolized to the right ventricle. All three patients were treated by immediate removal of the foreign body employing total cardiopulmonary bypass, with complete recovery in each case. This presentation describes our experience with these cases and the technical details of their management with a discussion of the indications for surgical removal of intracardiac foreign bodies. Case Reports CASE I. A twenty-four year old man received a .22 caliber gunshot wound of the left buttock during an From the Cora and Webb Mading Department of Surgery, Baylor Cc+ lege of Medicine, and the Ben Taub General Hospital, Houston, Texas. This work was supported in part by the USPHS (HE-05435 and HE05387). Reprint requests should be addressed to Dr. Beall, 1200 Moursund Ave., Houston, Texas 77025. Presented at the Twenty-Third Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April, 19-22. 1971.
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altercation in a local tavern. The injury apparently produced relatively minor symptoms initially, as he did not seek medical attention until eight hours later when he presented to the emergency room complaining of lower abdominal pain and fever. On examination the vital signs were normal except for a temperature of 101”~. There was lower abdominal tenderness without rebound or distention, and normal bowel sounds were heard. A small bullet entrance wound was seen in the lateral aspect of the left buttock. A moderate amount of blood was obtained on rectal examination and there was generalized rectal tenderness. Roentgenographic examination of the pelvis (Figure 1) demonstrated the missile; however, shortly thereafter, a scout film for a cystogram (Figure 2), performed to exclude injury to the urinary bladder, showed that the bullet had disappeared. A subsequent chest roentgenogram (Figure 3) revealed what appeared to be a .22 caliber missile within the cardiac silhouette. Cinefluoroscopy demonstrated movement of the missile with the wall of the right ventricle. Because of the patient’s stable condition in the eight hours prior to coming to the hospital, it was elected to remove the bullet from the heart before exploring the abdomen to avoid possible further migration of the bullet into the pulmonary arterial tree. The chest was entered through a right anterolateral, fourth intercostal space incision. Total cardiopulmonary bypass was instituted using a disposable bubble oxygenator primed with 5 per cent dextrose in distilled water under normothermic conditions [S]. A vascular clamp was placed across the main pulmonary artery and aorta, through the transverse sinus, to prevent the bullet from migrating into the pulmonary arterial circulation. A small, transverse, right ventriculotomy was performed, and the bullet was found trapped in the subvalvular mechanism of the tricuspid valve. It was removed without difficulty, the ventriculotomy was repaired, and cardiopulmonary bypass was discontinued. After closure of the thoracotomy incision, the abdomen was explored through a lower midline incision.
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Bullet
Figure 1. Case I. Roentgenogram bullet on the right.
of pelvis demonstrating
There was no blood or fluid in the abdomen, but a small retroperitoneal hematoma could be seen behind the rectum and in the area of the right iliac vessels. Since all distal pulses were present, the retroperitoneal space was not opened and a loop colostomy was performed. Subsequently, the patient did well until the eighteenth day when a moderate sized pulmonary embolus developed. Ligation of the inferior vena cava was performed, after which he recovered uneventfully and was discharged on the thirty-fifth postoperative day. One month later he was readmitted to the hospital and the colostomy was closed. He was last seen six months after operation at which time he had resumed normal activity without symptoms or disability.
In this case the venous injury was Comment: such that it did not require primary care, making it possible to perform the cardiac portion of the procedure first. Since there was no significant bleeding from the iliac vein into the retroperitoneal space, the peritoneum was left intact and the vein did not require repair at the time of laparotomy, although this may have been a factor in the
Embolus
to
Ventricle
Figure 2. Case I. Roentgenogram of the pelvis taken thirty minutes after the roentgenogram in Figure 1, demonstrating the disappearance of the bullet.
patient’s subsequent pulmonary embolus. the embolus and the right ventriculotomy, tient at no time demonstrated ventricular failure.
evidence
Despite the paof right
CASE II. A twenty-three year old man received a single gunshot wound of the right lower quadrant during a disagreement on a local street corner. The patient was brought immediately to the emergency room where he appeared to be in only moderate distress. Vital signs were normal and physical examination revealed diffuse abdominal tenderness and rigidity with a small entrance wound in the right lower quadrant. Rectal examination was not remarkable and urinalysis gave normal results. Roentgenogram of the abdomen was within normal limits and no missile was visible on the film. Roentgenograms of the chest taken shortly thereafter (Figure 4) revealed what appeared to be a .22 caliber missile lying within the cardiac shadow in a location corresponding to the ‘right ventricle. After the usual resuscitative measures, the abdomen was explored through a midline incision. Two through and through
Figure 3. Case 1. Roentgenograms of the chest demonstrating the presence of the bullet within the cardiac silhouette.
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Figure 4. Case II. Roentgenograms of the chest demonstrating the presence of the bullet within the cardiac silhouette.
perforations of the distal ileum were noted and a hematoma was seen retroperitoneally in the area of the right iliac vessels. These vessels were explored and a single hole was seen in the lateral wall of the right iliac vein. The vein was repaired primarily and the perforations of the ileum were debrided and closed. The upper part of the abdomen and diaphragm were examined carefully, but no injuries were noted, After closure of the abdomen, a portable roentgenogram of the chest was taken on the operating table to ensure that the location of the missile had not changed. The chest was entered through a median sternotomy incision and total cardiopulmonary bypass was instituted using the same technic as in the previous patient. The pulmonary artery was clamped, right atriotomy performed, and the right ventricle explored with a finger through the tricuspid valve. The bullet could be palpated easily, entrapped within the chordae tendineae. A clamp was passed into the ventricle beside the palpating finger and the bullet grasped and removed through the valve without difficulty. The patient’s general condition remained stable throughout both operative procedures, and the postoperative course was uneventful until the seventh day when a lomwgrade fever developed and a small subcutaneous wound infection involving only the lower end of the abdominal wound was discovered. After drainage of the wound, the patient became afebrile and recovery progressed rapidly. He has subsequently ‘returned to normal activity without symptoms.
Comment: This case represents the more usual situation in which the abdominal exploration must precede the open heart procedure. The necessity of taking a chest film with the patient on the operating table immediately preceding thoracotomy is emphasized. Although a median sternotomy is technically easier and avoids entering the right pleural space, the subsequent abdominal wound infection which occurred in this patient
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accentuates the possible hazard of this technic, namely, extension of an abdominal wound infection into the sternotomy wound. The transvalvular approach in removing the missile, although somewhat more difficult, is probably preferable since it avoids ventriculotomy. CASEIII. A thirty-nine year old woman was taken to the emergency room after being shot in the periumbilical area with a .25 caliber pistol. On examination she appeared quite inebriated but had normal vital Physical examination revealed an entrance signs. wound just above and to the right of the umbilicus with NO generalized abdomin’al tenderness and guarding. exit wound was found. All pulses were present and neurologic examination gave normal results. Roentgenographic examination of the abdomen showed nothing abnormal with no evidence of the missile. Chest roentgenogram (Figure 5) revealed a small caliber missile within the cardiac silhouette in a position corresponding to the right ventricle, After appropriate preparation, the patient underwent abdominal exploration through a midline incision. Perforations of the transverse colon and the midportion of the ileum were found, and a moderately large retroperitoneal hematoma was seen in the area of the inferior vena cava above the bifurcation. There was no wound of the liver or diaphragm. On exposing the vena cava, a single perforation was noted in its anterior wall. This was repaired primarily, after which the two perforations of the ileum were closed and the colon wound exteriorized as a colostomy. After closure of the abdomen, a portable chest roentgenogram was taken and demonstrated the location of the missile to be unchanged. A right anterolateral, fourth intercostal space incision was made as in case I, and cardiopulmonary bypass was instituted. The pulmonary artery was clamped, right atriotomy was performed, and the missile was removed through the tricuspid valve. The patient recovered uneventfully and was discharged on the tenth day. A
The American Journal of SUwerY
Bullet Embolus to Ventricle
Figor*e 5. Case 111.Roentgenograms of the chest demonstrating the bullet within the cardiac silhouege.
week later, however, signs of the postpericardiotomy syndrome developed, but responded rapidly to salicylates. Since then the patient has returned to normal activity without symptoms. Comment: An anterolateral thoracotomy was used in this patient to avoid continuity of the two incisions in the event an abdominal wound infection should develop. The transvalvular approach to the right ventricle again was used to avoid ventriculotomy. Comments
Embolization of a foreign body from a peripheral vein to the heart was first described by Davis in 1834 [I]. In that case, a large wooden fragment penetrated the right anterior part of the chest, entered the superior vena cava, and embolized to the right ventricle where it became lodged. The patient survived thirty-seven days before he died, presumably of sepsis. Since that time, approximately forty-three similar cases of venous embolization of foreign bodies to the heart have been reported in the English literature [4]. These foreign bodies have included iatrogenically introduced objects, such as hypodermic and radium needles and intravenous catheters, as well as a variety of pins, thorns, bones, bullets and fragments of other materials introduced through various types of wounds. Twenty-seven of the forty-three embolized objects have been bullets. One might expect that most of these would be propelled through the heart to become lodged in the pulmonary vascular tree. Although a few have followed this course, the majority have become entrapped in the right ventricle CZ]. In about half the cases, the bullet entered the
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venous circulation and migrated to the heart immediately after wounding whereas in the other half a delay of two days to thirteen months elapsed between wounding and embolization [41. In its earliest form elective cardiac surgery involved removal of foreign bodies from the heart. The first experiences in this area were described by Decker [5] in 1939. In a review of 100 cases of foreign bodies in the heart and pericardium, he described forty cases in which the objects were surgically removed, with only eight deaths. Among these cases were two in which the foreign body embolized to the heart via the systemic veins and subsequently was removed successfully. In the first of these cases a metal fragment was removed from the right ventricle by Bichat in 1916, and in the second a, bullet was removed from the right atrium by Duval in 1917. Both patients recovered. was exDuring World War II this experience panded considerably and Harken [6] described thirteen cases in which fragments were removed from the chambers of the heart using closed technics without mortality. None of these represented emboli. In 1952 Swan, Farsee, and Gouette [7] reported a case in which a shell fragment, which had entered the heart directly, was removed from the right ventricle using the technic of inflow occlusion. Hiebert [8] in Portland, Maine, was the first to remove an embolized bullet from the heart using cardiopulmonary bypass, as reported in I’ime magazine in 1964. In that case the patient was accidentally shot in the head with a .22 caliber rifle. The slug penetrated the skull, entered the transverse sinus, and migrated to the right ventricle, where it became lodged in the trabeculae. The bullet was removed through a right ventriculotomy and the patient recovered
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uneventfully. Padula, Sandler, and Camishion [h] in 1968 reported a case in which a bullet had embolized from the abdomen to the right ventricle fourteen years previously. This bullet was removed because of severe cardiac neurosis. Another similar case has been reported by Brewer [9]. With the three additional cases included in this report a total of six cases are known in which embolized bullets were removed from the heart using cardiopulmonary bypass. When it first became apparent during World War I that many foreign bodies could be removed from the heart with reasonable safety, considerable discussion was stimulated regarding the longterm effects of these objects and the indications for their removal. Decker [5], in a review of 100 cases of retained foreign bodies in the heart reported between 1900 and 1936, found that themortality associated with conservative management was 20 per cent and equalled that encountered with surgical removal during that time period. Since a number of the deaths in both categories resulted from infections, which today would not necessarily represent fatal complications, it is difficult to apply this information directly to current cases. That report did illustrate, however, the danger of fatal pulmonary embolus or infarction resulting from objects entering the right ventricle and of erosion through the heart wall of relatively large or sharp bodies. Harken and Zell [IO] in 1946 vigorously advocated the prophylactic removal of certain intracardiac foreign bodies for the following reasons : (1) to prevent embolism of the foreign body or associated thrombus, (2) to reduce the danger of bacterial endocarditis, (3) to diminish the incidence of myocardial damage, (4) to prevent recurrent pericardial effusions, and (5) to prevent or alleviate cardiac neurosis. In support of the first indication, Harken cited two cases in which embolism causing hemiplegia resulted from a foreign body retained in the left atrium in one patient and the left ventricle in the other. In 1942 Harken [11] demonstrated the spontaneous appearance of bacterial endocarditis and septic emboli after implantation of foreign bodies in the cardiac chambers of dogs. Clinically, he found that four of the five foreign bodies which were cultured after their removal from one of the cardiac chambers grew out bacteria. Two of these were found in small abscesses within mural thrombi. He also described three cases in which erosion of the myocardium resulted from retained intracardiac fragments. Two of these represented migratory foreign bodies within a ventricular chamber and
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one ended fatally. In 1949 Fritz et al [12] implanted sterile foreign bodies in various locations in the hearts of 62 dogs. Two dogs died of systemic embolization and one of infection. The remainder had no serious consequences from the implanted metal fragments. Swan, Farsee, and Gouette [7] found experimentally that foreign bodies within the heart chambers were generally tolerated well, but if they were in such a location that they were impinged on by a valve structure or myocardial wall during systole, erosion occurred. Recurrent pericardial effusion is common in patients with retained foreign bodies, but only in those in whom the object penetrated the pericardium originally [I 3,141. Some additional information may be gained, particularly in reference to embolic foreign bodies in the right ventricle, from the numerous reports of embolized intravenous catheters. In a recent review ‘of this subject, Blair, Hunziker, and Flanagan [15] described sixty-one such cases with significant complications occurring in 23 per cent and half of these resulting in death. These complications included one case of atria1 fibrillation, five of thrombosis, two of perforation, and five of endocarditis with deaths occurring in each category. Although always considering it last, every investigator of this subject has stressed the importance of the psychologic morbidity of intracardiac foreign bodies. Bland and Beebe [13], in their twenty year follow-up study of World War II veterans, found that every patient was genuinely concerned about the foreign material in his heart and five of the forty patients were totally incapacitated by their neurosis in the absence of any physiologic abnormality. From these observations, it becomes apparent that foreign bodies may behave differently depending on their exact location, size, configuration, and degree of contamination. Although the majority of these objects in most locations within the heart may remain dormant indefinitely and produce no serious difficulty, a significant number, particularly the large objects within the myocardium and most of the objects within the heart chambers, will produce irreversible or fatal complications if left undisturbed. Cardiac surgery today has advanced to the point where most of these foreign bodies can be removed with negligible risk in a patient who is otherwise in fairly good health. In the three cases presented herein, the bullet had passed through contaminated bowel at relatively low velocity before entering the venous sys-
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tern. (Figure 6b.) Also, each had become lodged in the right ventricle in an area where it impinged on the $apillary muscles and chordae tendineae of the tricuspid valve. Thus, all but one of the indications for surgical removal cited by Harken were present. In most instances the area where the missile has entered the venous system should be dealt with first, primarily to control hemorrhage. After this procedure, under the same anesthetic, the patient should be positi,oned appropriately for thoracotomy and a portable roentgenogram of the chest taken to confirm the continued presence of the missile within the heart. If the initial procedure involves open bowel or another source of contamination, a clean instrument setup should be used for thoracotomy. This simplest and quickest approach to the heart is through a median sternotomy. If, however, laparotomy is required in conjunction with the open heart procedure, the chest should be entered through a right anterolateral incision. (Figure 6a.) In this way, continuity between the two incisions is avoided and an infection developing in the abdominal incision will not spread direfitly to involve the sternum. After placing the patient on total cardiopulmonary bypass, it is important to occlude the main pulmonary artery with a vascular clamp before manipulating the heart to prevent the bullet from accidentally falling into the pulmonary artery from the ventricle. Initially, a right atriotomy should be performed, for in most instances it is possible to palpate and remove the object through the tricuspid valve. (Figure 6c.) If, however, this a transverse ventriculotomy is unsuccessful, through the pulmonary outflow tract should provide direct visualization of the foreign body within the ventricular chamber. These patients seem to recover remarkably well. With the exception of the patient with the postpericardiotomy syndrome, none has suffered any ill effects from the cardiac portion of the operation.
Ventricle
ger inherent in a retained intracardiac foreign body depends on its exact location, its size and shape, and its degree of contamination. With the relative safety of cardiac surgery today, it is recommended that most intracardiac foreign bodies be removed, particularly those that are large or lie within a cardiac chamber. References 1. Straus
2.
3.
Summary 5.
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Figure 6. Drawings illustrating features of the cases described: (a) incisions employed in cases I and III; (b) pathways followed by missiles; (c) technic of transvalvular extraction of the bullet from the right ventricle.
4.
Three cases are presented in which a bullet embolized from a major vein of the lower trunk to the right ventricle. In each instance the bullet was removed using cardiopulmonary bypass shortly after the patient’s admission to the hospital. All three patients recovered completely. The technical details of their management and the indications for removal of intracar’diac foreign bodies are discussed. It is concluded that the dan-
Embolus
6.
7.
R: Pulmonary embolism caused by a lead bullet following a gunshot wound of the abdomen. Arch Path 33: 63, 1942. Harken DE, Williams AC: Foreign bodies in and in relation to the thoracic blood vessels and heart. II. Migratory foreign bodies within the blood vascular system. Amer J Surg 72: 80, 1946. Cooley DA, ‘Beall AC Jr, Grondin P: Open-heart operations using disposable oxygenators. 5 per cent dextrose prime and normothermia. Surgery 52: 713, 1962. Padula RT, Sandler SC, Camishion RC: Delayed bullet embolization to the heart following abdominal gunshot wound. Amer Surg 169,: 599, 1969. Decker HR: Foreign bodies in the heart and pericardium: should they be removed? J Thorac Surg 9: 62, 1939. Harken DE: Foreign bodies in and in relation to the thoracic blood vessels and heart. I. Techniques for ‘approaching and removing foreign bodies from the chambers of the heart. Surg Gynec Obstet 83: 117,
1946. Swan H, Farsee JH, Gouette
EM: Foreign bodies in the heart: indication for and instance of removal wit,h temporary interruption of cardiac blood flow. Amer Surg 13,5c314. 1952. 8. The Wandering Bullet. Time, p 1512, December 25, 1964. 9. Brewer 1LA III: Personal communication.
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et al
Harken DE, Zoll the thoracic the removal behavior of
PM: Foreign bodies in and in relation to blood vessels and heart. III. Indication for of intracardiac foreign bodies and the the heart during manipulation. Amer
Heart J 32: 1, 1946.
13.
Med 274: 1039, 1966. 14. Barrett NR: Foreign bodies in the cardiovascular
11. Harken 12.
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DE: Experiments in cardiac surgery. I. Bacterial endocarditis. J Thorac Surg 11: 656, 1942. Fritz JM, Newman MM, Jamplis RW, Adams WE: Fate of
cardiac foreign bodies. Surgery 25: 869, 1949. Bland EF, Beebe GW: Missiles in the heart: a 20 year follow-up report of World War II cases. New Eng J
15.
Brit J Surg 37: 416, 1950. Blair E, Hunziker R, Flanagan Surgery 67: 457, 1970.
ME: Catheter
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In the past the entry of bullets and other missiles into the circulation with subsequent embolization was encountered almost exclusively in battle casualties. More recently, however, with the greater private use of firearms, an increasing number of these injuries are being seen in civilian hospitals. In these cases a variety of different migratory pathways are possible, depending on the site of entry of the missile into the vascular system and the subsequent effects of blood flow and gravity. In reviews of this subject, Straus [I] in 1942 and Harken and Williams [2] in 1946 described a total of forty-five cases of embolic foreign bodies, nine of which represented missiles entering the systemic venous system peripherally and migrating to the right ventricle. During the last four years, we have encountered three cases in which missiles entered the venous system in the lower part of the abdomen and embolized to the right ventricle. All three patients were treated by immediate removal of the foreign body employing total cardiopulmonary bypass, with complete recovery in each case. This presentation describes our experience with these cases and the technical details of their management with a discussion of the indications for surgical removal of intracardiac foreign bodies. Case Reports CASE I. A twenty-four year old man received a .22 caliber gunshot wound of the left buttock during an From the Cora and Webb Mading Department of Surgery, Baylor Cc+ lege of Medicine, and the Ben Taub General Hospital, Houston, Texas. This work was supported in part by the USPHS (HE-05435 and HE05387). Reprint requests should be addressed to Dr. Beall, 1200 Moursund Ave., Houston, Texas 77025. Presented at the Twenty-Third Annual Meeting of the Southwestern Surgical Congress, Las Vegas, Nevada, April, 19-22. 1971.
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altercation in a local tavern. The injury apparently produced relatively minor symptoms initially, as he did not seek medical attention until eight hours later when he presented to the emergency room complaining of lower abdominal pain and fever. On examination the vital signs were normal except for a temperature of 101”~. There was lower abdominal tenderness without rebound or distention, and normal bowel sounds were heard. A small bullet entrance wound was seen in the lateral aspect of the left buttock. A moderate amount of blood was obtained on rectal examination and there was generalized rectal tenderness. Roentgenographic examination of the pelvis (Figure 1) demonstrated the missile; however, shortly thereafter, a scout film for a cystogram (Figure 2), performed to exclude injury to the urinary bladder, showed that the bullet had disappeared. A subsequent chest roentgenogram (Figure 3) revealed what appeared to be a .22 caliber missile within the cardiac silhouette. Cinefluoroscopy demonstrated movement of the missile with the wall of the right ventricle. Because of the patient’s stable condition in the eight hours prior to coming to the hospital, it was elected to remove the bullet from the heart before exploring the abdomen to avoid possible further migration of the bullet into the pulmonary arterial tree. The chest was entered through a right anterolateral, fourth intercostal space incision. Total cardiopulmonary bypass was instituted using a disposable bubble oxygenator primed with 5 per cent dextrose in distilled water under normothermic conditions [S]. A vascular clamp was placed across the main pulmonary artery and aorta, through the transverse sinus, to prevent the bullet from migrating into the pulmonary arterial circulation. A small, transverse, right ventriculotomy was performed, and the bullet was found trapped in the subvalvular mechanism of the tricuspid valve. It was removed without difficulty, the ventriculotomy was repaired, and cardiopulmonary bypass was discontinued. After closure of the thoracotomy incision, the abdomen was explored through a lower midline incision.
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Bullet
Figure 1. Case I. Roentgenogram bullet on the right.
of pelvis demonstrating
There was no blood or fluid in the abdomen, but a small retroperitoneal hematoma could be seen behind the rectum and in the area of the right iliac vessels. Since all distal pulses were present, the retroperitoneal space was not opened and a loop colostomy was performed. Subsequently, the patient did well until the eighteenth day when a moderate sized pulmonary embolus developed. Ligation of the inferior vena cava was performed, after which he recovered uneventfully and was discharged on the thirty-fifth postoperative day. One month later he was readmitted to the hospital and the colostomy was closed. He was last seen six months after operation at which time he had resumed normal activity without symptoms or disability.
In this case the venous injury was Comment: such that it did not require primary care, making it possible to perform the cardiac portion of the procedure first. Since there was no significant bleeding from the iliac vein into the retroperitoneal space, the peritoneum was left intact and the vein did not require repair at the time of laparotomy, although this may have been a factor in the
Embolus
to
Ventricle
Figure 2. Case I. Roentgenogram of the pelvis taken thirty minutes after the roentgenogram in Figure 1, demonstrating the disappearance of the bullet.
patient’s subsequent pulmonary embolus. the embolus and the right ventriculotomy, tient at no time demonstrated ventricular failure.
evidence
Despite the paof right
CASE II. A twenty-three year old man received a single gunshot wound of the right lower quadrant during a disagreement on a local street corner. The patient was brought immediately to the emergency room where he appeared to be in only moderate distress. Vital signs were normal and physical examination revealed diffuse abdominal tenderness and rigidity with a small entrance wound in the right lower quadrant. Rectal examination was not remarkable and urinalysis gave normal results. Roentgenogram of the abdomen was within normal limits and no missile was visible on the film. Roentgenograms of the chest taken shortly thereafter (Figure 4) revealed what appeared to be a .22 caliber missile lying within the cardiac shadow in a location corresponding to the ‘right ventricle. After the usual resuscitative measures, the abdomen was explored through a midline incision. Two through and through
Figure 3. Case 1. Roentgenograms of the chest demonstrating the presence of the bullet within the cardiac silhouette.
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Figure 4. Case II. Roentgenograms of the chest demonstrating the presence of the bullet within the cardiac silhouette.
perforations of the distal ileum were noted and a hematoma was seen retroperitoneally in the area of the right iliac vessels. These vessels were explored and a single hole was seen in the lateral wall of the right iliac vein. The vein was repaired primarily and the perforations of the ileum were debrided and closed. The upper part of the abdomen and diaphragm were examined carefully, but no injuries were noted, After closure of the abdomen, a portable roentgenogram of the chest was taken on the operating table to ensure that the location of the missile had not changed. The chest was entered through a median sternotomy incision and total cardiopulmonary bypass was instituted using the same technic as in the previous patient. The pulmonary artery was clamped, right atriotomy performed, and the right ventricle explored with a finger through the tricuspid valve. The bullet could be palpated easily, entrapped within the chordae tendineae. A clamp was passed into the ventricle beside the palpating finger and the bullet grasped and removed through the valve without difficulty. The patient’s general condition remained stable throughout both operative procedures, and the postoperative course was uneventful until the seventh day when a lomwgrade fever developed and a small subcutaneous wound infection involving only the lower end of the abdominal wound was discovered. After drainage of the wound, the patient became afebrile and recovery progressed rapidly. He has subsequently ‘returned to normal activity without symptoms.
Comment: This case represents the more usual situation in which the abdominal exploration must precede the open heart procedure. The necessity of taking a chest film with the patient on the operating table immediately preceding thoracotomy is emphasized. Although a median sternotomy is technically easier and avoids entering the right pleural space, the subsequent abdominal wound infection which occurred in this patient
556
accentuates the possible hazard of this technic, namely, extension of an abdominal wound infection into the sternotomy wound. The transvalvular approach in removing the missile, although somewhat more difficult, is probably preferable since it avoids ventriculotomy. CASEIII. A thirty-nine year old woman was taken to the emergency room after being shot in the periumbilical area with a .25 caliber pistol. On examination she appeared quite inebriated but had normal vital Physical examination revealed an entrance signs. wound just above and to the right of the umbilicus with NO generalized abdomin’al tenderness and guarding. exit wound was found. All pulses were present and neurologic examination gave normal results. Roentgenographic examination of the abdomen showed nothing abnormal with no evidence of the missile. Chest roentgenogram (Figure 5) revealed a small caliber missile within the cardiac silhouette in a position corresponding to the right ventricle, After appropriate preparation, the patient underwent abdominal exploration through a midline incision. Perforations of the transverse colon and the midportion of the ileum were found, and a moderately large retroperitoneal hematoma was seen in the area of the inferior vena cava above the bifurcation. There was no wound of the liver or diaphragm. On exposing the vena cava, a single perforation was noted in its anterior wall. This was repaired primarily, after which the two perforations of the ileum were closed and the colon wound exteriorized as a colostomy. After closure of the abdomen, a portable chest roentgenogram was taken and demonstrated the location of the missile to be unchanged. A right anterolateral, fourth intercostal space incision was made as in case I, and cardiopulmonary bypass was instituted. The pulmonary artery was clamped, right atriotomy was performed, and the missile was removed through the tricuspid valve. The patient recovered uneventfully and was discharged on the tenth day. A
The American Journal of SUwerY
Bullet Embolus to Ventricle
Figor*e 5. Case 111.Roentgenograms of the chest demonstrating the bullet within the cardiac silhouege.
week later, however, signs of the postpericardiotomy syndrome developed, but responded rapidly to salicylates. Since then the patient has returned to normal activity without symptoms. Comment: An anterolateral thoracotomy was used in this patient to avoid continuity of the two incisions in the event an abdominal wound infection should develop. The transvalvular approach to the right ventricle again was used to avoid ventriculotomy. Comments
Embolization of a foreign body from a peripheral vein to the heart was first described by Davis in 1834 [I]. In that case, a large wooden fragment penetrated the right anterior part of the chest, entered the superior vena cava, and embolized to the right ventricle where it became lodged. The patient survived thirty-seven days before he died, presumably of sepsis. Since that time, approximately forty-three similar cases of venous embolization of foreign bodies to the heart have been reported in the English literature [4]. These foreign bodies have included iatrogenically introduced objects, such as hypodermic and radium needles and intravenous catheters, as well as a variety of pins, thorns, bones, bullets and fragments of other materials introduced through various types of wounds. Twenty-seven of the forty-three embolized objects have been bullets. One might expect that most of these would be propelled through the heart to become lodged in the pulmonary vascular tree. Although a few have followed this course, the majority have become entrapped in the right ventricle CZ]. In about half the cases, the bullet entered the
Volume 122, November1971
venous circulation and migrated to the heart immediately after wounding whereas in the other half a delay of two days to thirteen months elapsed between wounding and embolization [41. In its earliest form elective cardiac surgery involved removal of foreign bodies from the heart. The first experiences in this area were described by Decker [5] in 1939. In a review of 100 cases of foreign bodies in the heart and pericardium, he described forty cases in which the objects were surgically removed, with only eight deaths. Among these cases were two in which the foreign body embolized to the heart via the systemic veins and subsequently was removed successfully. In the first of these cases a metal fragment was removed from the right ventricle by Bichat in 1916, and in the second a, bullet was removed from the right atrium by Duval in 1917. Both patients recovered. was exDuring World War II this experience panded considerably and Harken [6] described thirteen cases in which fragments were removed from the chambers of the heart using closed technics without mortality. None of these represented emboli. In 1952 Swan, Farsee, and Gouette [7] reported a case in which a shell fragment, which had entered the heart directly, was removed from the right ventricle using the technic of inflow occlusion. Hiebert [8] in Portland, Maine, was the first to remove an embolized bullet from the heart using cardiopulmonary bypass, as reported in I’ime magazine in 1964. In that case the patient was accidentally shot in the head with a .22 caliber rifle. The slug penetrated the skull, entered the transverse sinus, and migrated to the right ventricle, where it became lodged in the trabeculae. The bullet was removed through a right ventriculotomy and the patient recovered
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uneventfully. Padula, Sandler, and Camishion [h] in 1968 reported a case in which a bullet had embolized from the abdomen to the right ventricle fourteen years previously. This bullet was removed because of severe cardiac neurosis. Another similar case has been reported by Brewer [9]. With the three additional cases included in this report a total of six cases are known in which embolized bullets were removed from the heart using cardiopulmonary bypass. When it first became apparent during World War I that many foreign bodies could be removed from the heart with reasonable safety, considerable discussion was stimulated regarding the longterm effects of these objects and the indications for their removal. Decker [5], in a review of 100 cases of retained foreign bodies in the heart reported between 1900 and 1936, found that themortality associated with conservative management was 20 per cent and equalled that encountered with surgical removal during that time period. Since a number of the deaths in both categories resulted from infections, which today would not necessarily represent fatal complications, it is difficult to apply this information directly to current cases. That report did illustrate, however, the danger of fatal pulmonary embolus or infarction resulting from objects entering the right ventricle and of erosion through the heart wall of relatively large or sharp bodies. Harken and Zell [IO] in 1946 vigorously advocated the prophylactic removal of certain intracardiac foreign bodies for the following reasons : (1) to prevent embolism of the foreign body or associated thrombus, (2) to reduce the danger of bacterial endocarditis, (3) to diminish the incidence of myocardial damage, (4) to prevent recurrent pericardial effusions, and (5) to prevent or alleviate cardiac neurosis. In support of the first indication, Harken cited two cases in which embolism causing hemiplegia resulted from a foreign body retained in the left atrium in one patient and the left ventricle in the other. In 1942 Harken [11] demonstrated the spontaneous appearance of bacterial endocarditis and septic emboli after implantation of foreign bodies in the cardiac chambers of dogs. Clinically, he found that four of the five foreign bodies which were cultured after their removal from one of the cardiac chambers grew out bacteria. Two of these were found in small abscesses within mural thrombi. He also described three cases in which erosion of the myocardium resulted from retained intracardiac fragments. Two of these represented migratory foreign bodies within a ventricular chamber and
588
one ended fatally. In 1949 Fritz et al [12] implanted sterile foreign bodies in various locations in the hearts of 62 dogs. Two dogs died of systemic embolization and one of infection. The remainder had no serious consequences from the implanted metal fragments. Swan, Farsee, and Gouette [7] found experimentally that foreign bodies within the heart chambers were generally tolerated well, but if they were in such a location that they were impinged on by a valve structure or myocardial wall during systole, erosion occurred. Recurrent pericardial effusion is common in patients with retained foreign bodies, but only in those in whom the object penetrated the pericardium originally [I 3,141. Some additional information may be gained, particularly in reference to embolic foreign bodies in the right ventricle, from the numerous reports of embolized intravenous catheters. In a recent review ‘of this subject, Blair, Hunziker, and Flanagan [15] described sixty-one such cases with significant complications occurring in 23 per cent and half of these resulting in death. These complications included one case of atria1 fibrillation, five of thrombosis, two of perforation, and five of endocarditis with deaths occurring in each category. Although always considering it last, every investigator of this subject has stressed the importance of the psychologic morbidity of intracardiac foreign bodies. Bland and Beebe [13], in their twenty year follow-up study of World War II veterans, found that every patient was genuinely concerned about the foreign material in his heart and five of the forty patients were totally incapacitated by their neurosis in the absence of any physiologic abnormality. From these observations, it becomes apparent that foreign bodies may behave differently depending on their exact location, size, configuration, and degree of contamination. Although the majority of these objects in most locations within the heart may remain dormant indefinitely and produce no serious difficulty, a significant number, particularly the large objects within the myocardium and most of the objects within the heart chambers, will produce irreversible or fatal complications if left undisturbed. Cardiac surgery today has advanced to the point where most of these foreign bodies can be removed with negligible risk in a patient who is otherwise in fairly good health. In the three cases presented herein, the bullet had passed through contaminated bowel at relatively low velocity before entering the venous sys-
The
American
Journel
of
Sugery
Bullet
tern. (Figure 6b.) Also, each had become lodged in the right ventricle in an area where it impinged on the $apillary muscles and chordae tendineae of the tricuspid valve. Thus, all but one of the indications for surgical removal cited by Harken were present. In most instances the area where the missile has entered the venous system should be dealt with first, primarily to control hemorrhage. After this procedure, under the same anesthetic, the patient should be positi,oned appropriately for thoracotomy and a portable roentgenogram of the chest taken to confirm the continued presence of the missile within the heart. If the initial procedure involves open bowel or another source of contamination, a clean instrument setup should be used for thoracotomy. This simplest and quickest approach to the heart is through a median sternotomy. If, however, laparotomy is required in conjunction with the open heart procedure, the chest should be entered through a right anterolateral incision. (Figure 6a.) In this way, continuity between the two incisions is avoided and an infection developing in the abdominal incision will not spread direfitly to involve the sternum. After placing the patient on total cardiopulmonary bypass, it is important to occlude the main pulmonary artery with a vascular clamp before manipulating the heart to prevent the bullet from accidentally falling into the pulmonary artery from the ventricle. Initially, a right atriotomy should be performed, for in most instances it is possible to palpate and remove the object through the tricuspid valve. (Figure 6c.) If, however, this a transverse ventriculotomy is unsuccessful, through the pulmonary outflow tract should provide direct visualization of the foreign body within the ventricular chamber. These patients seem to recover remarkably well. With the exception of the patient with the postpericardiotomy syndrome, none has suffered any ill effects from the cardiac portion of the operation.
Ventricle
ger inherent in a retained intracardiac foreign body depends on its exact location, its size and shape, and its degree of contamination. With the relative safety of cardiac surgery today, it is recommended that most intracardiac foreign bodies be removed, particularly those that are large or lie within a cardiac chamber. References 1. Straus
2.
3.
Summary 5.
Volume 122. November 1971
to
Figure 6. Drawings illustrating features of the cases described: (a) incisions employed in cases I and III; (b) pathways followed by missiles; (c) technic of transvalvular extraction of the bullet from the right ventricle.
4.
Three cases are presented in which a bullet embolized from a major vein of the lower trunk to the right ventricle. In each instance the bullet was removed using cardiopulmonary bypass shortly after the patient’s admission to the hospital. All three patients recovered completely. The technical details of their management and the indications for removal of intracar’diac foreign bodies are discussed. It is concluded that the dan-
Embolus
6.
7.
R: Pulmonary embolism caused by a lead bullet following a gunshot wound of the abdomen. Arch Path 33: 63, 1942. Harken DE, Williams AC: Foreign bodies in and in relation to the thoracic blood vessels and heart. II. Migratory foreign bodies within the blood vascular system. Amer J Surg 72: 80, 1946. Cooley DA, ‘Beall AC Jr, Grondin P: Open-heart operations using disposable oxygenators. 5 per cent dextrose prime and normothermia. Surgery 52: 713, 1962. Padula RT, Sandler SC, Camishion RC: Delayed bullet embolization to the heart following abdominal gunshot wound. Amer Surg 169,: 599, 1969. Decker HR: Foreign bodies in the heart and pericardium: should they be removed? J Thorac Surg 9: 62, 1939. Harken DE: Foreign bodies in and in relation to the thoracic blood vessels and heart. I. Techniques for ‘approaching and removing foreign bodies from the chambers of the heart. Surg Gynec Obstet 83: 117,
1946. Swan H, Farsee JH, Gouette
EM: Foreign bodies in the heart: indication for and instance of removal wit,h temporary interruption of cardiac blood flow. Amer Surg 13,5c314. 1952. 8. The Wandering Bullet. Time, p 1512, December 25, 1964. 9. Brewer 1LA III: Personal communication.
Morton
10.
et al
Harken DE, Zoll the thoracic the removal behavior of
PM: Foreign bodies in and in relation to blood vessels and heart. III. Indication for of intracardiac foreign bodies and the the heart during manipulation. Amer
Heart J 32: 1, 1946.
13.
Med 274: 1039, 1966. 14. Barrett NR: Foreign bodies in the cardiovascular
11. Harken 12.
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DE: Experiments in cardiac surgery. I. Bacterial endocarditis. J Thorac Surg 11: 656, 1942. Fritz JM, Newman MM, Jamplis RW, Adams WE: Fate of
cardiac foreign bodies. Surgery 25: 869, 1949. Bland EF, Beebe GW: Missiles in the heart: a 20 year follow-up report of World War II cases. New Eng J
15.
Brit J Surg 37: 416, 1950. Blair E, Hunziker R, Flanagan Surgery 67: 457, 1970.
ME: Catheter
The Amerlcw~ Joumrl
system.
embolism.
of Suway