MAGIC BULLET: A RARE CASE OF PROJECTILE EMBOLIZATION FROM THE RIGHT CHEST TO THE RIGHT VENTRICLE

Objectives: In ballistic injuries such as gunshot wounds, it is known that trajectory, depth of penetration, and injury patterns are difficult to predict. In exceptionally rare instances, gunshot wounds may result in embolization of retained bullets through the vascular system. Due to their low resistance, and thin walls, venous structures are more susceptible to bullet penetration and embolization. Here we present a fascinating case of bullet embolization from an infraclavicular gunshot wound, through the right subclavian vein, lodging within the right ventricle myocardium. In this fascinating case, a 30 year old male presented after sustaining a gunshot wound to his right chest. He was hemodynamically stable with evidence for a penetrating ballistic injury to the right infraclavicular region of the chest along the lateral border of the clavicle near the deltopectoral groove. He underwent CT which raised our concerns for retained pericardial bullet versus intracardiac bullet. Echocardiography confirmed endocardial versus intramyocardial location of the bullet within the right ventricular apex. Given the precarious location and potential for dire complications, we elected for surgical removal. The patient was managed surgically through a median sternotomy. He was placed on cardiopulmonary bypass which allowed for ventriculotomy and removal of the bullet which was lodged intramyocardially within the apex of the right ventricle. Postoperatively, he recovered well without issue. This case represents a rare challenge in management of traumatic bullet embolization given the confounding issues. Firstly, the patient was an otherwise healthy and hemodynamically stable after sustaining a gunshot wound which could have produced pneumothorax or exsanguinating. Additionally, imaging confirmed no evidence of pericardial effusion or findings concerning for “through and through” cardiac injury or transmediastinal injury. Also, given the rarity of this condition, no consensus approach to management has been defined. Several recent studies have highlighted the safety of nonoperative management with observation, which does appear to be beneficial in select cases. However, we proceeded with the maximally invasive option which we felt this was the optimal choice given the size of the bullet, its perilous location within the myocardium, and concern for mobility and embolic potential of the retained bullet. This case highlights the clinical and therapeutic challenges associated with bullet embolization which represents an almost negligible subclass of gunshot wounds and ballistic injuries. In this exciting case, we were able to produce favorable results for a patient sustaining an exceedingly rare, but potentially lethal injury pattern with an unexpected presentation.

Methods:

Results:

Conclusion: