Cardiac bullet embolus after thoracic vena cava penetrating injury causing tricuspid valve insufficiency

Conservative Management of Retained Cardiac Missiles: Case Report and Literature Review

“…19,21,25,26,34,38,39,41 Wandering intracavitary missiles are apparent on serial imaging and should also be removed to prevent distal embolization of a main pulmonary artery or systemic artery. 3,13,23,31,80 Dysrhythmia, valve dysfunction, or intracardiac shunt caused by the presence of a retained missile and left heart location are also indications for elective retrieval of retained missiles within the heart. 1,7,27,55,65,66,76,78,80 Based on the high risk of complications and ease of retrieval, we placed RCMs within the pericardial sac into the soft indication for retrieval category.…”

“…3,13,23,31,80 Dysrhythmia, valve dysfunction, or intracardiac shunt caused by the presence of a retained missile and left heart location are also indications for elective retrieval of retained missiles within the heart. 1,7,27,55,65,66,76,78,80 Based on the high risk of complications and ease of retrieval, we placed RCMs within the pericardial sac into the soft indication for retrieval category. Removal of pericardial retained missiles most often requires subxiphoid pericardial window.…”

“…Cardiopulmonary bypass with arteriotomy and extraction was successfully employed. Less inva- Tamponade/significant pericardial effusions Entry into heart after contamination 6,8,26,45 Irregular missile (nail, chicken wire, saw blade fragment) 19,21,25,26,34,36,38,39,45 Wandering intracardiac missile on serial imaging 3,13,23,31,80 Intracardiac shunt 27,65 Posttraumatic dysrhythmia 35, 55,66 Hemodynamically significant valvular abnormality 7,78,80 Left heart location 1 Proximity to vital structure (major coronary artery/vein or conduction system) with concern for future complication 49 Pericardial location: based on historical literature with high complication rate and eases of retrieval 1,88 Postinjury fevers with concern for missile providing source for sepsis 3,27,33 Intraoperatively during mediastinal exploration for other indication in setting of accurate localization and minimal expected difficulty in retrieval Inability to establish long term follow up for serial examination/imaging sive, endovascular techniques for the management of RCM have also been described. Controlled embolization from the right ventricle into the lower extremity venous system that uses rapid fluoroscopic table repositioning has been successful in 2 cases.…”

Bullet and Shrapnel Embolism: When “Uncommon” Meets “Dangerous”

“…Embolized venous projectiles may be associated with a multitude of potential complications including, but not limited to, pulmonary artery embolism, cardiac valve dysfunction, dysrhythmias, intraventricular communications, cardiac conduction defects, endocarditis, abscess formation, sepsis, thrombosis, tissue erosion, hemorrhage, pseudoaneurysm, cardiac ischemia from erosion into coronary vessels, and thrombophlebitis [7,21,31]. However, it is important to keep in mind that venous emboli are only symptomatic in approximately one-third of cases, with clinically detectable complications related to the initial injury often noted months or even years later.…”

“…Due to the heterogeneity of anatomic locations and differing projectile-specific propensity to migrate and cause complications, a broad range of clinical presentations have been described. For example, cardiac-related findings may include valvular insufficiency [21,31], broadly defined "cardiac irritability" such as the appearance of arrhythmias [41], and even sudden death [51]. Common pulmonary manifestations of BSE include chest pain, cough, dyspnea, and hemoptysis [22,52].…”