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Noninvasive preoperative localization of an intracardiac bullet
International Journal of Cardiology, 33 (1991) 427-429 0 1991 Elsevier Science Publishers B.V. All rights reserved
CARD10
427 0167-5273/91/$03.50
13611
Brief Reports
Noninvasive preoperative
localization of an intracardiac bullet
Prasanta K. Karak, Sanjiv Sharma and Mira Rajani Department of Cardiovascular Radiology, All India Institute of Medical Sciences, New Delhi, India (Received
18 April 1991; revision
accepted
2X May 1991)
A 40-year-old patient with intracardiac gunshot injury is reported. The bullet was localized preoperatively within the pericardium at the junction of the right atrium and the inferior caval vein and was removed successfully at surgery. The role of various imaging techniques in the preoperative localization of intracardiac missiles is discussed.
Key words: Heart, missile injuries: Ultrasound;
Computed tomography
Non-fatal gunshot injury to the heart is rare in the civilian population [l]. Depending upon its location within the heart, an intracardiac bullet may remain asymptomatic or may result in immediate (haemo/ pneumopericardium, haemo/ pneumothorax, lung contusion) or delayed (recurrent pericarditis, endocarditis, thrombo-embolism, aneurysmal dilatation in the region of the bullet) complications [l-4]. We recently encountered a case of gunshot injury to the heart in which the bullet was localized preoperatively within the pericardium and successfully removed at surgery. Case Report
A 40-year-old male was admitted with a gunshot injury sustained 6 hours previously. On examination, the patient was afebrile, with a blood pressure of 110/80 mmHg, pulse rate of 80 per minute and respi-
ratory rate at 22 per minute. The entry wound was located in the left 4th posterior intercostal space. No exit wound was seen. Examination of the chest and cardiovascular system was normal. Chest X-rays (postero-anterior and lateral views) at admission (Fig. la & b) showed a single bullet near the diaphragmatic surface of the heart and bilateral consolidation of the lower lobes of the lungs. Fluoroscopy showed a pendulum-like movement of the bullet with each heart beat. Ultrasound (Fig. 2a) revealed a single 2.7 cm bullet located in the posterior pericardium at the junction of the right atrium and the inferior caval vein. Computed tomography (Fig. 2b, c) confirmed these findings and, in addition, showed bilateral small haemothoraxes. The patient subsequently underwent surgery. At operation, the bullet was found in the posterior pericardium at the junction of the right atrium and the inferior caval vein. The postoperative period was uneventful and the patient was discharged 7 days later.
Discussion Correspondence to: Dr S. Sharma, Dept. of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India.
Gun-shot injury to the heart is common during war time, but an increasing number of similar injuries have
428
Fig. 1. (a) X-ray chest postero-anterior view showing consolidation in both lower zones and a single radio-opaque bullet near the fundal gas shadow (arrowhead). (b) Lateral view showing the anteriorly located radio-opaque bullet along the diaphragmatic surface.
been reported among the civilians [l]. The portal of entry can be either via direct penetrating injury or via embolization through the systemic venous system. Bullets within the pericardium or the outer part of the myocardium are often well tolerated and the patients may remain asymptomatic. Severe psychological stress, leading to anxiety neurosis and recurrent pericarditis or pericardial effusion have also, nonetheless, been reported [l]. Bullets within the inner myocardium, or within the cardiac cavities, behave differently, carry a high risk of endocarditis, thromboembolism, aneurysma1 dilatation in the region of the bullet and involvement of the coronary vessels by scar tissue [3]. Most authors advocate immediate surgical removal of the bullet, even if it is asymptomatic, in order to avoid late complication [ 1,451. Accurate preoperative localization of the bullet within the heart is important for optimal surgical and anaesthetic technique. The patient with an intrapericardial bullet does not require cardiopulmonary by-
pass, whereas the latter is essential for the surgical removal of a bullet within the cardiac cavities. Chest X-rays localize the bullet within the cardiac silhouette but fail to differentiate between cavitary, myocardial and pericardial locations. Gravity-dependent movement within the cardiac silhouette may be detected if chest X-rays are taken in the erect and supine positions. This movement can be seen when the bullet is either within the heart or in the pericardium. Fluoroscopy helps to differentiate between intrapericardial and intracavitary locations. It shows gravity dependent movement in the cases of free intracavitary or intrapericardial location. In addition, an intrapericardial bullet shows a pendulum-like movement with each heart beat. Ultrasound can demonstrate the exact anatomic location of the bullet and the associated complications, if any. It is especially helpful for intraoperative localization in order to detect the exact site of the bullet at the time of surgery [5]. Bullets found free within the cavi-
429 ties are known to migrate and may lead to serious problems during surgery [2,3]. Computed tomography also helps in accurate preoperative localization and detection of associated complications. It readily detects the exact number of bullets or pellets, their location when multiple, the presence of haemo- or pneumothorax, and the status of the lung parenchyma and the bony skeleton. In the present case, computed tomography provided additional information regarding the presence of small bilateral haemothoraxes and absence of haemo- or pneumopericardium. Computed tomography as a diagnostic modality in the preoperative localization of intracardiac bullet injuries has, as far as we know, not previously been described. It appears to be the most accurate non-invasive imaging modality for optimal preoperative diagnosis, and should become the investigation of choice for diagnostic evaluation of cardiac injury produced by penetrating missiles.
Acknowledgement
We acknowledge the contribution of Dr. KS. Iyer, from the Department of Cardiothoracic and Vascular Surgery, who operated upon this patient.
References
Fig. 2. (a) Ultrasound showing linear echogenic bullet (arrowhead) with distal acoustic shadowing at the junction of the inferior caval vein and the right atrium. tb) Tomogram showing change in the position of the bullet and surgical emphysema. (c) Computerized tomographic scan showing the bullet at the junction of the inferior caval vein with the right atrium, producing streak artefacts with small haemothorax on right side.
Padula RT, Sandier SC, Camishion RC. Delayed bullet embolization to the heart following abdominal gun-shot wound. Ann Surg 1969;169:599-602. Bland EF, Beebe GW. Missiles in the heart: a twenty year follow up report of world war II cases. N Engl J Med 1966;274:1039-1046. Samaan HA. Intracardiac foreign body. Br J Surg 1970:57:685-687. Sakai K, Hoshimo S, Osawa M. Needle in the heart: two dimensional echocardiographic findings. Am J Cardiol 1984;53:1482. Amsell BJ, Mart MVD. Bock LD, Haasen RV. The importance of two-dimensional echocardiography in the location of a bullet embolus to the right ventricle. Ann Thorac Surg 1988;46:102-103.
CARD10
427 0167-5273/91/$03.50
13611
Brief Reports
Noninvasive preoperative
localization of an intracardiac bullet
Prasanta K. Karak, Sanjiv Sharma and Mira Rajani Department of Cardiovascular Radiology, All India Institute of Medical Sciences, New Delhi, India (Received
18 April 1991; revision
accepted
2X May 1991)
A 40-year-old patient with intracardiac gunshot injury is reported. The bullet was localized preoperatively within the pericardium at the junction of the right atrium and the inferior caval vein and was removed successfully at surgery. The role of various imaging techniques in the preoperative localization of intracardiac missiles is discussed.
Key words: Heart, missile injuries: Ultrasound;
Computed tomography
Non-fatal gunshot injury to the heart is rare in the civilian population [l]. Depending upon its location within the heart, an intracardiac bullet may remain asymptomatic or may result in immediate (haemo/ pneumopericardium, haemo/ pneumothorax, lung contusion) or delayed (recurrent pericarditis, endocarditis, thrombo-embolism, aneurysmal dilatation in the region of the bullet) complications [l-4]. We recently encountered a case of gunshot injury to the heart in which the bullet was localized preoperatively within the pericardium and successfully removed at surgery. Case Report
A 40-year-old male was admitted with a gunshot injury sustained 6 hours previously. On examination, the patient was afebrile, with a blood pressure of 110/80 mmHg, pulse rate of 80 per minute and respi-
ratory rate at 22 per minute. The entry wound was located in the left 4th posterior intercostal space. No exit wound was seen. Examination of the chest and cardiovascular system was normal. Chest X-rays (postero-anterior and lateral views) at admission (Fig. la & b) showed a single bullet near the diaphragmatic surface of the heart and bilateral consolidation of the lower lobes of the lungs. Fluoroscopy showed a pendulum-like movement of the bullet with each heart beat. Ultrasound (Fig. 2a) revealed a single 2.7 cm bullet located in the posterior pericardium at the junction of the right atrium and the inferior caval vein. Computed tomography (Fig. 2b, c) confirmed these findings and, in addition, showed bilateral small haemothoraxes. The patient subsequently underwent surgery. At operation, the bullet was found in the posterior pericardium at the junction of the right atrium and the inferior caval vein. The postoperative period was uneventful and the patient was discharged 7 days later.
Discussion Correspondence to: Dr S. Sharma, Dept. of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110029, India.
Gun-shot injury to the heart is common during war time, but an increasing number of similar injuries have
428
Fig. 1. (a) X-ray chest postero-anterior view showing consolidation in both lower zones and a single radio-opaque bullet near the fundal gas shadow (arrowhead). (b) Lateral view showing the anteriorly located radio-opaque bullet along the diaphragmatic surface.
been reported among the civilians [l]. The portal of entry can be either via direct penetrating injury or via embolization through the systemic venous system. Bullets within the pericardium or the outer part of the myocardium are often well tolerated and the patients may remain asymptomatic. Severe psychological stress, leading to anxiety neurosis and recurrent pericarditis or pericardial effusion have also, nonetheless, been reported [l]. Bullets within the inner myocardium, or within the cardiac cavities, behave differently, carry a high risk of endocarditis, thromboembolism, aneurysma1 dilatation in the region of the bullet and involvement of the coronary vessels by scar tissue [3]. Most authors advocate immediate surgical removal of the bullet, even if it is asymptomatic, in order to avoid late complication [ 1,451. Accurate preoperative localization of the bullet within the heart is important for optimal surgical and anaesthetic technique. The patient with an intrapericardial bullet does not require cardiopulmonary by-
pass, whereas the latter is essential for the surgical removal of a bullet within the cardiac cavities. Chest X-rays localize the bullet within the cardiac silhouette but fail to differentiate between cavitary, myocardial and pericardial locations. Gravity-dependent movement within the cardiac silhouette may be detected if chest X-rays are taken in the erect and supine positions. This movement can be seen when the bullet is either within the heart or in the pericardium. Fluoroscopy helps to differentiate between intrapericardial and intracavitary locations. It shows gravity dependent movement in the cases of free intracavitary or intrapericardial location. In addition, an intrapericardial bullet shows a pendulum-like movement with each heart beat. Ultrasound can demonstrate the exact anatomic location of the bullet and the associated complications, if any. It is especially helpful for intraoperative localization in order to detect the exact site of the bullet at the time of surgery [5]. Bullets found free within the cavi-
429 ties are known to migrate and may lead to serious problems during surgery [2,3]. Computed tomography also helps in accurate preoperative localization and detection of associated complications. It readily detects the exact number of bullets or pellets, their location when multiple, the presence of haemo- or pneumothorax, and the status of the lung parenchyma and the bony skeleton. In the present case, computed tomography provided additional information regarding the presence of small bilateral haemothoraxes and absence of haemo- or pneumopericardium. Computed tomography as a diagnostic modality in the preoperative localization of intracardiac bullet injuries has, as far as we know, not previously been described. It appears to be the most accurate non-invasive imaging modality for optimal preoperative diagnosis, and should become the investigation of choice for diagnostic evaluation of cardiac injury produced by penetrating missiles.
Acknowledgement
We acknowledge the contribution of Dr. KS. Iyer, from the Department of Cardiothoracic and Vascular Surgery, who operated upon this patient.
References
Fig. 2. (a) Ultrasound showing linear echogenic bullet (arrowhead) with distal acoustic shadowing at the junction of the inferior caval vein and the right atrium. tb) Tomogram showing change in the position of the bullet and surgical emphysema. (c) Computerized tomographic scan showing the bullet at the junction of the inferior caval vein with the right atrium, producing streak artefacts with small haemothorax on right side.
Padula RT, Sandier SC, Camishion RC. Delayed bullet embolization to the heart following abdominal gun-shot wound. Ann Surg 1969;169:599-602. Bland EF, Beebe GW. Missiles in the heart: a twenty year follow up report of world war II cases. N Engl J Med 1966;274:1039-1046. Samaan HA. Intracardiac foreign body. Br J Surg 1970:57:685-687. Sakai K, Hoshimo S, Osawa M. Needle in the heart: two dimensional echocardiographic findings. Am J Cardiol 1984;53:1482. Amsell BJ, Mart MVD. Bock LD, Haasen RV. The importance of two-dimensional echocardiography in the location of a bullet embolus to the right ventricle. Ann Thorac Surg 1988;46:102-103.