La presencia de cuerpos extraños intracardiacos y su tratamiento suponen todavía un tema controvertido dada la variedad de localizaciones en las que se puede presentar y las diferentes manifestaciones clínicas e implicaciones pronósticas de cada una de ellas. El número de casos publicados en los que no existe puerta de entrada directa del cuerpo a las cavidades cardiacas, diagnosticando o asumiendo su embolización a distancia, es mucho más reducido. Presentamos el caso de un varón adulto con herida cervical por arma de fuego y dos cuerpos extraños alojados en ventrículo derecho sin puerta de entrada directa.

Case Report A 39-year-old male patient was transferred to emergency room by mobile intensive care unit after receiving a firearm wound in the neck while hunting: accidentally hit by a shotgun. Physical examination highlighted the existence of multiple entry holes at right side face and neck and some above the shoulder girdle line, the rest of the thorax and abdomen did not present skin lesions. Axial tomography (CT) showed multiple pellets in the face and neck tissues and two intracardiac pellets in the right ventricle. He did not present pneumothorax, pneumopericardium or pericardial effusion. He underwent surgical intervention by otolaryngology and vascular teams due to right cervical hematoma and secondary alterations to the shot in the right internal jugular vein. Enucleation of the right eye was also necessary. Echocardiographic study showed the presence of a small hyperechogenic mass with posterior acoustic shadow located in interventricular septum. Another similar structure was also found, in the right ventricle, next to the tricuspid annulus: normal tricuspid valve function. Considering the trajectory (blue triangle) of the shot and the absence of thoracic complications, we thought about the plausibility of projectile embolization from the right internal jugular vein. Discussion The presence of projectiles in different cardiac structures can occur by direct impact (the most frequent mechanism), passing through thoracic and/or abdominal structures to be lodged in the pericardium and/or myocardium. They are often accompanied by manifestations such as pericardial effusion or pneumothorax as a result of their trajectory. Embolization to the heart is a much more uncommon mechanism by impacting in another anatomical location such as the neck or lower extremitie. In these cases there may be no extra-cardiac manifestations and can be an incidental finding of a previous event. In our case the intracardiac pellets were s was handled conservatively and the rest of the wounds produced by the shot showed a good evolution. The patient remained asymptomatic from a cardiological point of view during hospitalization and follow up. There is no evidence to support the therapeutic attitude that should be followed in these cases. When the patient is stable and the projectiles are non-mobile, conservative treatment with periodic follow-up is a suitable option. Abstract P191 Figure. A. 3D echo, B. Xplane, C. CT VR.

74-year-old woman without cardiovascular risk factors. Se came to the out-paint clinic due to chest pain. Normal ECG. Spherical, pedunculated, mobile, slightly hyper-echogenic mass at the level of the posterior papillary muscle by transthoracic echocardiography. Cardiac MR (CMR) was performed for further evaluation: mobile mass of 4 x 5mm, located in the mitral subvalvular apparatus was confirmed, with similar intensity to the myocardium in the SSFP sequences. In T2 TSE sequences, the mass was hyperintense and in the perfusion sequences marked hypoperfusion was found. In early late gad enhancement the mass was hypointense and in the late phase, hyper-intense. According to these findings papillary fibroelastoma was our first diagnostic choice. The coronary angio showed a significant RCA stenosis. The tumor was surgically removed and aorto-coronary bypass was perfomed. Pathological anatomy confirmed the suspected diagnosis. Papillary fibroelastoma is the second most frequent benign primary cardiac tumor, originated mainly in the valvular endocardium. The most frequent localization of these tumors is in the aortic valve. The vast majority are asymptomatic and their diagnosis is usually incidental (as in the case described), although severe symptoms may appear secondary to embolic phenomena such as cerebrovascular event, acute myocardial infarction or even sudden death by coronary embolization. The initial diagnosis is usually made by echocardiography. CMR is a reference diagnostic technique in the study of cardiac tumors: provides a better location and tissue characterization. Regarding the treatment, it is recommended the exeresis, in symptomatic patients with embolic phenomenon or in asymptomatic patients with a high risk of embolization (tumors> 1cm or very mobile). This case is of special interest since the location of a fibroelastoma in the mitral subvalvular apparatus is exceptional (there are very few cases described in the literature). In addition, although in the study of cardiac tumors pathological anatomy remains the reference diagnostic method, this case shows how cardio-MRI can correctly guide diagnosis even in small and mobile tumors. Abstract P651 Figure. A.3D TOE B.Surgical image C.CMR D. PA

La valoración de las masas cardíacas es un problema clínico relativamente frecuente para las técnicas de imagen cardíca. Presentamos el caso de una masa cardíaca con localización inusual en el que las técnicas de imagen permitieron orientar el diagnóstico, que como no puede ser de otro modo, se confirmó en la cirugía.