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Sumario Vol. 43 - Nº 1 Enero - Marzo 2014

Cardiac Gunshot Wound

Daniel Marelli, Oscar E. Pisano, Luis A. Calafell,
Facundo N. Herrera Mujica

Hospital San Juan de Dios de La Plata.
(1900) La Plata, Buenos Aires, Argentina
E mail

Recibido 13-NOV-13 – ACEPTADO después de revisión 21 de ENERO de 2013.

The authors declare not having a conflict of interest.

Rev Fed Arg Cardiol. 2013; 43(1): 45-48


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SUMMARY

The treatment of cardiac gunshot injuries is controversial because of the small number of cases studied in each center and the variety of wound locations and clinical manifestations.
We report the case of an adult with cardiac gunshot injury and bullet housing in the interventricular septum (IVS). The patient remained hemodynamically stable from admission, confirming the presence of metallic foreign body in the IVS by chest x-ray (XR), transthoracic echocardiogram (TTE) and chest computed tomography (CT). Conservative treatment was adopted with good clinical outcome at a 12-month follow-up.

Key words: Gunshot wound. Interventricular septum. Conservative treatment.

 

INTRODUCTION
The treatment of cardiac wounds is not standardized, among other reasons, due to the variety of locations, complications that the bullets may produce, and the scant number of patients that survive, which makes preparing studies with an appropriate number of patients difficult.

In this presentation, a case attended in our institution is described, due to a gunshot wound in the cardiac region and bullet lodged in the interventricular septum (IVS), treated in a conservative manner with a favorable clinical evolution.

 

CLINICAL CASE
Male, 22-year-old patient, with no known cardiovascular risk factors, admitted in the Coronary Unit of our hospital, referred from another institution, with a diagnosis of chest gunshot wound, with an 8-hour evolution, with entrance in the fourth left intercostal space, 5 mm orifice, between the anterior and midclavicular axillary line, associated to left hemopneumothorax.

The patient was lucid, hemodynamically stable, with normal blood pressure and no fever. He mentioned pain of a moderate intensity in the area of the wound, with left pleural drainage tube, with serohematic effusion. His vital signs were blood pressure 110/60 mmHg, heart rate of 72 bpm, and 18 cycles per minute of respiratory rate.

Cardiovascular system: no jugular ingurgitation, preserved point of maximum impulse, present and symmetrical peripheral pulses, normal sounding S1 and S2 in the 4 foci, no extra sounds.

Respiratory system: good ventilatory mechanics, decreased air inflow in the left pulmonary base, no extra sounds. Oxygen saturation with 98% ambient air.

Laboratory tests at admittance within normal limits.

ECG: sinus rhythm, 72 bpm, QRS axis +70°, p 0.08 sec, PR 0.14 sec, QRS 0.08 sec, QTm 0.38, good R progression in precordial leads, no repolarization disorders.

Chest X-rays: preserved cardiothoracic index (0.48), with central cardiac metallic density imaging of 5 mm. Expanded pulmonary fields, no pleural effusion, with left pleural drainage tube (Figure 1).

Figure 1. Chest X-rays showing central cardiac metallic density imaging
and left pleural drainage tube. Expanded pulmonary fields.

Chest computed tomography: It displays metallic density imaging in IVS associated to left pleural effusion in a mild degree (Figure 2).

Figure 2. Chest computed tomography with metallic
density image in IVS associated to left pleural effusion.

Transthoracic echo: Left ventricle (LV) with normal diameters, thickness and parietal motility. Preserved systolic ventricular function. Hyperreflective image is observed of approximately 6 x 7 mm at the apical level in the interventricular septum between its anterior and posterior portions. No color flow is detected at such level.

Tricuspid aortic valve, preserved opening. Mitral valve without structural alterations. Normal left atrium. Normal thoracic aorta.

Normal right cavities. Proper right ventricular (RV) free wall motility. Mild to moderate pericardial effusion (13 mm), with predominance in the RV free wall, with no signs of cardiac tamponade (Figures 3a-b-c).

Figure 3a. Transthoracic echo (TTE). Apical 4-chamber view, showing hyperreflective bullet in the apical segment of the interventricular septum, with no evidence of intracardiac shunt.

 

Figure 3b. TTE. Apical 4-chamber view with reflective image compatible with a foreign object within the IVS.

 

Figure 3c. TTE: Subcostal view showing pericardial effusion with no signs of cardiac tamponade.

 

EVOLUTION
He evolved favorably, hemodynamically stable, with no fever, and no signs of pump failure. In agreement with the cardiology and cardiovascular surgery services, it is decided to follow a waiting management, withdrawing the pleural drainage tube on the fourth day of admittance. He remained asymptomatic, stable, with no signs of local complications at the level of the location of the bullet. TTE is repeated on the fifth day of admittance, showing a free pericardium, with no signs of interventricular septal orifice at the level of the bullet (apical segment of the anterior and posterior septal junction).

Hospital discharge is granted after two weeks of stay with cardiology outpatient follow-up. TTE is made 12 months after discharge, which yields normal LV diameters, thickness and parietal motility, with preserved systolic function. Hyperreflective image maintained in the IVS apical region with no local complications. Free pericardium (Figures 4a-b).

Figure 4a. TTE. Apical 4-chamber view showing bullet retained
in the apical region of the IVS with no local complications.

 

Figure 4b. Long axis showing free pericardium.

 

DISCUSSION
Penetrating wounds in the cardiac area still have a severe prognosis and are a significant cause of morbi-mortality, although mortality has decreased over time. Most affected people are young, previously healthy individuals.

The most common causes of penetrating cardiac trauma are gunshot wounds (as in the presented case) and by knife [1]. Penetrating cardiac trauma may also have a iatrogenic source (cardiac catheters, pacemakers, thoracic trocars, etc) [2].

The underlying pathophysiologic mechanism depends on the kind of injury, the size of the wound, and the affected neighboring structures. Thus, stab wounds, in general small with a pericardial laceration, produce cardiac tamponade in 80-90% of the cases, when sealing quickly. On the contrary, in gunshot wounds, the pericardial injury is significant and bleeding intense, causing nearly always, hypovolemic shock [1].

The most frequently affected cardiac chamber is the RV (37%), then the LV (25%), RA (27%), LA (5.7%) and less frequently the coronary arteries (10%), pulmonary artery and ascending aorta (2.8%) and vena cava (2.7). In turn, the wounds that bleed the most are those involving the aorta, followed by lesions located in the LV, RV, LA and RA [3].

Only a small group of patients with significant cardiac injury reach an emergency service and their clinical manifestations range from complete hemodynamic stability to acute cardiovascular collapse with cardiorespiratory arrest (CRA) and shock [1].

Classically, 4 forms of clinical presentation are reported: cardiac tamponade (the pericardial wound is small), hemorrhagic / hypovolemic shock (larger pericardial wound and the patients may present severe shock associated to massive hemothorax), and an asymptomatic variety, with no signs of tamponade or shock (it happens when the cardiac damage is mild and there is little bleeding; not frequent) [1]. Our patient belongs to the last group of clinical presentation.

The patients that are admitted in hypovolemic shock present a greater likelihood to die (26.2%) than those with cardiac tamponade (4.65%) or with minor symptoms (1.8%). There is a greater probability of dying with involvement of the atria or in several cardiac chambers (18.5 and 28.5% respectively), than with lesion in an isolated ventricle (8.2%) [4].

The initial choice of the supplementary diagnostic method to verify if the wound involves the heart depends on the hemodynamic stability of the patient. If he/she is stable, it is possible to start with diagnostic procedures (X-rays, CT, TTE) to evaluate a possible cardiac lesion. If the patient is hemodynamically affected, he/she will require an immediate therapeutic management with emergency thoracotomy. Some authors suggest practicing a subxiphoid pericardial window with a diagnostic goal, even to the patients with a benign presentation. However, invasive procedures are gradually being replaced by noninvasive ones, so that ultrasound is currently the initial study in precordial lesions with no indication of immediate thoracotomy [5]. Considering the hemodynamic stability of our patient at admittance, an indication of noninvasive diagnostic procedures was chosen.

The timely moment of a therapeutic intervention in essence, happens in one of three moments and it depends mainly, on the hemodynamic situation of the patient when he/she reaches the emergency room: immediate (thoracotomy in the ER), urgent (in the OR, 1-4 hours after admittance) and late intervention (24 hours after admittance) [6].

Cardiac lesions that require an immediate repair comprise parietal defects, coronary arteries lesions, and great vessels lesions. The lesions that can be repaired late under extracorporeal circulation (ECC) include intracardiac lesions as septal defects, valve lesions and ventricular aneurysms[8]. On the occasion of the patient presenting severe heart failure (HF), the repair will be done at the time of the initial intervention under ECC.

The bullets lodged in the IVS, at times, are usually well tolerated and only require a waiting management, as long as the patient remains asymptomatic and hemodynamically stable. The surgical exploration and removal should be considered before the appearance of arrhythmias, HF, interventricular septal orifice or cardiac tamponade [7]. The pericardial location is the one most frequently presenting symptoms if an active intervention is not adopted [8].

The surgical results, in their different series, show a mortality of 16.6% and a morbidity of 22% respectively. Surgical mortality is related to surgery delay, or with complex lesions and/or gunshot wounds [9].

The range of post-operative complications in these patients is quite wide and may evolve both symptomatically and asymptomatically. Intracardiac defects, valve lesions, ventricular aneurysms, retention of foreign objects and consequences of ischemia in ECG are described as the most important sequelae; however, the need of a new surgery due to these complications is very rare [10].

Chest auscultation during the post-operative period is important to rule out murmurs; if there is any, it is necessary to request TTE [6].

Although literature does not clarify the frequency or time of follow-up in these patients, the convenience and significance of this follow-up is emphasized. A careful physical examination is advised, besides ECG and chest X-rays in asymptomatic patients. In patients that present clinical symptoms of HF, TTE should be requested, and possibly cardiac catheterization, before the chance of short-circuits, fistulae or valve diseases [1].

The late complications of a retained bullet depend on its type, size and location. The most frequent complications are persistent chest pain, pericarditis, embolization, endocarditis, sepsis, intracardiac fistulae and cardiac neurosis [8].

The reported clinical case was initially asymptomatic, with no parietal, valvular or great vessels lesions that would condition hemodynamic instability. The bullet embedded within the IVS did not cause local complications, so a waiting management was adopted, and a follow-up was decided by cardiology outpatient office, with clinical evaluations, ECG and TTE every 6 months.

 

CONCLUSIONS
Cardiac penetrating lesions are not frequent; however, they are responsible for an important rate of morbi-mortality. The main risk factor for death is a gunshot wound (13 times greater to a stab wound). An early recognition of the lesion and a rapid intervention is necessary. The thoracic lesions should be repaired surgically in one of 3 periods: immediate, urgent or late thoracotomy. A conservative strategy is advised in asymptomatic, hemodynamically stable patients, without local complications, since such cases present a favorable clinical evolution [9].

 

BIBLIOGRAPHY

  1. Kamalı S, Aydın MT, Akan A, et al. Penetrating cardiac injury: factors affecting outcome.Ulus Travma Acil Cerrahi Derg 200117(3):225-30.
  2. Meredith JW, Hoth JJ. Thoracic trauma: when and how to intervene.Surg Clin North Am 2007; 87 (1): 95-118.
  3. ActisDato GM, Arslanian A, Di Marzio P, et al. Posttraumatic and iatrogenic foreign bodies in the heart: report of fourteen cases and review of the literature. J Thorac Cardiovasc Surg 2003; 126 (2): 408-14.
  4. FreixinetGilart J, Hernández Rodríguez H, MartínezVallina P, et al. Guidelines for the diagnosis and treatment of thoracic traumatism. Arch Bronconeumol 2011; 47 (1): 41-9.
  5. Pereira BM, Nogueira VB, Calderan TR, et al. Penetrating cardiac trauma: 20-y experience from a university teaching hospital.J Surg Res. 2013; 183 (2): 792-7.
  6. Rodrigues AJ, Furlanetti LL, Faidiga GB,et al. Penetrating cardiac injuries: A 13 year retrospective evaluation from a Braziliam trauma center. Interact Cardio Vasc Thorac Surg 2005; 4 (3): 212-5.
  7. Cañas A, Almodóvar LL, Lima PP, et al. Cardiac shotgun pellet in the interventricular septum. Rev Esp Cardiol 2007; 60 (9): 994-5
  8. Castriconi M, Festa P, Bartone G, et al. Penetrating cardiac injuries. Two case reports. Ann Ital Chir 2013 Apr 24; 84. pii: S2239253X13020987.
  9. Gómez G, Hola J. Trauma penetrante cardíaco en la unidad de emergencia del Hospital Carlos Van Buren. Rev Chil Cir 2009; 61(5): 453-7.

Publication: March 2014

 
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