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Table of Contents  
Year : 2017  |  Volume : 11  |  Issue : 3  |  Page : 790-793  

The journey of harmless bullet: The perioperative care of penetrating cardiac injury

Department of Anesthesiology and Pain Management, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA

Date of Web Publication22-Nov-2016

Correspondence Address:
Ahmad Abou-Leila
415 Howard Street, Evanston, IL 60202
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0259-1162.194578

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Traumatic injuries to the heart contribute significantly to trauma are associated with high mortality. Cardiac gunshot wounds (GSW) are considered more lethal compared to other injuries and present several unique challenges to the anesthesia management and perioperative care. We are reporting a rare case of a trauma victim who survived a GSW to the heart. We will discuss the perioperative care of penetrating cardiac injuries, the role of the anesthesia team in resuscitation, safe anesthesia induction, cardiopulmonary bypass management, and the essential role of intraoperative transesophageal echocardiogram imaging.

Keywords: Cardiac injury, penetrating trauma, perioperative, trauma

How to cite this article:
Abou-Leila A, Voronov G. The journey of harmless bullet: The perioperative care of penetrating cardiac injury. Anesth Essays Res 2017;11:790-3

How to cite this URL:
Abou-Leila A, Voronov G. The journey of harmless bullet: The perioperative care of penetrating cardiac injury. Anesth Essays Res [serial online] 2017 [cited 2020 Apr 6];11:790-3. Available from:

   Introduction Top

The sequelae of most penetrating cardiac injuries are death, with 90% of cases arriving considered dead on arrival.[1],[2] This high mortality stems from tamponade or massive hemorrhage.[3],[4] The medical literature recommends immediate surgical intervention for survivors.[3]

Our case represents one of the outliers. A 17-year-old male presented, with a single gunshot wound (GSW) to the left costal margin. On further workup, the bullet injured the spleen and traversed the left diaphragm, crossing through the posterior wall of the left ventricle to lodge in the interventricular septum below the tricuspid valve, without signs of tamponade that occurs in more than 80% of victims.[5] The patient was hemodynamically stable on presentation, and he underwent elective bullet extraction on the next day.

   Case Report Top

A 17-year-old male patient presented to trauma unit with a single GSW to left thoraco-abdomen at the anterior axillary line. On presentation, the patient was fully awake and hemodynamically stable. Primary and secondary surveys ruled out other injuries. Chest X-ray demonstrated a retained missile in the cardiac silhouette and left hemithorax [Figure 1]. A left chest tube was inserted, and an emergent transthoracic echocardiogram showed normal ejection fraction, without pericardial fluid or valvular injury, and the presence of high echogenic material below the tricuspid valve septal leaflets. Computed tomography (CT) of the chest and abdomen showed retained foreign body in the interventricular septum and a splenic injury with active extravasation. The patient remained hemodynamically stable and taken to the operating room for exploratory laparotomy. He underwent splenectomy and repair of a laceration of the left hepatic lobe. Postoperatively, a CT angiogram of the aorta with three-dimensional reconstruction showed the retained bullet in the intraventricular septum [Figure 2]. The preoperative transesophageal echocardiogram (TEE) confirmed the same location of the projectile [Figure 3].
Figure 1: Lateral chest X-ray showing the shadow of retained bullet in the cardiac silhouette

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Figure 2: Computed tomography chest three-dimensional reconstruction showing the bullet in the right heart, below the tricuspid valve

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Figure 3: Preoperative transesophageal echocardiogram showing the hyperechoic shadow of the bullet below the tricuspid valve, no pericardial effusion noticed

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The patient returned to the OR for elective sternotomy and extraction of the intracardiac bullet with cardiopulmonary bypass (CPB). In the OR patient was stable, electrocardiogram (EKG) showed sinus rhythm without atrioventricular-block. General anesthesia (GA) was induced using propofol 2 mg/kg, fentanyl 2 mcg/kg, and rocuronium 1 mg/kg, before proceeding with successful intubation. After confirming the bullet immobility and the location away from pulmonary artery catheter (PAC) route, the PAC was inserted successfully intraoperative TEE showed the bullet location in the intraventricular septum, Doppler flow imaging ruled out ventricular septal defect (VSD) or tricuspid valve regurgitation. The transgastric short axis imaging revealed normal contractility. The pre-CPB period was uneventful. The patient then underwent aortic and bicaval cannulation, and CBP was initiated. Cardiac inspection showed an injury in the posterior wall of the left ventricular (LV) with adherent clot without exit wound [Figure 4]. Right atriotomy, bullet extraction, repair of the bullet cavity, closure of LV posterior wall hole were then performed [Figure 5]. Before weaning from CPB, TEE was repeated to rule out any bullet residuals. Doppler flow was used to rule out new VSD or tricuspid regurgitation, bubble test done to confirm no new intracardiac shunts [Figure 6]. Weaning from the CBP was uneventful. The chest was closed, and the patient was extubated the same day and discharged home 4 days later. He has since followed up several times without any sequelae from his injury.
Figure 4: The entry wound in the posterior wall of the left ventricular

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Figure 5: The atriotomy and the bullet extraction

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Figure 6: The postbypass transesophageal echocardiogram - the agitated saline study. Notice the entrapment of air microbubbles in the right heart. No signs of new shunt

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   Discussion Top

Penetrating cardiac injuries are rare, and cardiac GSWs are associated with the highest mortality rate among all traumatic injuries.[6],[7] Conventional wisdom recommends the necessity of immediate surgical intervention. Our case report highlights the importance of triaging these victims into two groups, the clinically or imaging unstable and the stable patients. In our case, the extensive preoperative workup and the elective surgical intervention led to a favorable outcome.

Patients presenting with hemorrhagic shock, or impending collapse revealed by occult shock [8] or the presence of tamponade benefit from immediate surgical exploration. Resuscitation and emergency department thoracotomy (EDT) have a limited role.[9] EDT is indicated only in patients without vitals. Expedited transfer to OR with midline sternotomy allows extensive exploration of the heart, major vessels, and bilateral pleural spaces [1],[3] and prompt repair with or without CPB.

Patients with normal physiological status, on admission, benefit from a comprehensive preoperative workup. This approach allows precise localization of the missiles, diagnosis of associated injuries, and differentiate between high-risk and low-risk retained missiles [Table 1].[10]
Table 1: Retained missiles management

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Based on the workup results, patients are assigned for early elective, delayed retrieval, or no intervention.[11],[12] Location also determines the need for CPB. Nonoperative retrieval of the bullet can be utilized in certain situations.[12] In our case, early elective retrieval of the bullet is indicated because of the proximity to the tricuspid valve and interventricular septum and the conduction system.

Anesthesia management for cardiac GSW injuries differs widely according to the severity of the clinical condition. The general principles of anesthesia management include maintaining hemodynamic stability on induction, management of CPB, and TEE imaging.

Preserving hemodynamic stability requires thorough preoperative evaluation and planning. Symptoms and signs to look for are signs of hypoperfusion, abnormal cardiac filling, abnormal vital signs such as pulsus paradoxus, a shock index >0.9,[8] EKG for pulsus alternans, and the perioperative cardiac imaging. GA is always required for cardiac injury repair. Preinduction arterial line insertion and availability of massive transfusion of blood products, and defibrillator are essential for success.[13],[14] There are two options for anesthesia induction, either inhalation induction while maintaining spontaneous breathing, or intravenous induction with agents with minimal cardiac depression such as ketamine.[15] The hemodynamic goal is to maintain preload, high sinus rate, and after load. Some authors recommend against volume overload as it may increase the risk of bleeding.[16],[17] A physiologically intact patient can undergo regular induction. Our patient was hemodynamically stable, and anesthesia induction and operative management were uneventful.

CBP indications are presented in [Table 2].
Table 2: Cardiopulmonary bypass indication in penetrating cardiac injury

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In our case, CPB was indicated because of the intracavitary location of the bullet and proximity to the tricuspid valve.

TEE is essential in all three phases of perioperative care.[18],[19] Preoperative TEE is very sensitive to detect tamponade, shunts, valve injury, or coronary artery injuries and reveals the precise location of the bullet. Intraoperatively in the pre-CPB period, TEE is indicated to guide cannulation, monitor volume status, myocardial contractility, and changes in location of mobile bullets. Post-CPB, TEE is indicated to rule out any residual missiles, iatrogenic shunts, or new valve injury.[18],[19],[20] In our case, we used color Doppler flow to check the valve status and agitated saline to rule out new shunts. It is imperative to rule out any concomitant esophageal injury before TEE probe insertion, and this highlights the importance of extensive preoperative workup in stable patients.[21]


We like to thank Drs. Piotr Aljindi, James Yon, Jaroslav Tymouch, Feodor Gloss, Ned Nasr, and Medical student Prajay Rathore.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Clarke DL, Quazi MA, Reddy K, Thomson SR. Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa. J Thorac Cardiovasc Surg 2011;142:563-8.  Back to cited text no. 2
Kang N, Hsee L, Rizoli S, Alison P. Penetrating cardiac injury: Overcoming the limits set by Nature. Injury 2009;40:919-27.  Back to cited text no. 3
Henderson VJ, Smith RS, Fry WR, Morabito D, Peskin GW, Barkan H, et al. Cardiac injuries: Analysis of an unselected series of 251 cases. J Trauma 1994;36:341-8.  Back to cited text no. 4
Buckman RF Jr., Badellino MM, Mauro LH, Asensio JA, Caputo C, Gass J, et al. Penetrating cardiac wounds: Prospective study of factors influencing initial resuscitation. J Trauma 1993;34:717-25.  Back to cited text no. 5
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Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 2009;67:1426-30.  Back to cited text no. 8
Van Waes OJ, Van Riet PA, Van Lieshout EM, Hartog DD. Immediate thoracotomy for penetrating injuries: Ten years' experience at a Dutch level I trauma center. Eur J Trauma Emerg Surg 2012;38:543-51.  Back to cited text no. 9
Poston RS, Sloane RW Jr., Morgan BR, Smith DC, Smithson JB, Hickey MS. Elective removal of an intramyocardial bullet. South Med J 2001;94:464-6.  Back to cited text no. 10
Symbas PN, Picone AL, Hatcher CR, Vlasis-Hale SE. Cardiac missiles. A review of the literature and personal experience. Ann Surg 1990;211:639-47.  Back to cited text no. 11
Lundy JB, Johnson EK, Seery JM, Pham T, Frizzi JD, Chasen AB. Conservative management of retained cardiac missiles: Case report and literature review. J Surg Educ 2009;66:228-35.  Back to cited text no. 12
Grocott HP, Gulati H, Srinathan S, Mackensen GB. Anesthesia and the patient with pericardial disease. Can J Anaesth 2011;58:952-66.  Back to cited text no. 13
Fiedler M, Nelson LA. Cardiac tamponade. Int Anesthesiol Clin 2005;43:33-43.  Back to cited text no. 14
Stanley TH, Weidauer HE. Anesthesia for the patient with cardiac tamponade. Anesth Analg 1973;52:110-4.  Back to cited text no. 15
Hashim R, Frankel H, Tandon M, Rabinovici R. Fluid resuscitation-induced cardiac tamponade. J Trauma 2002;53:1183-4.  Back to cited text no. 16
Catarino PA, Halstead JC, Westaby S. Attempted nail-gun suicide: Fluid management in penetrating cardiac injury. Injury 2000;31:209-11.  Back to cited text no. 17
Skoularigis J, Essop MR, Sareli P. Usefulness of transesophageal echocardiography in the early diagnosis of penetrating stab wounds to the heart. Am J Cardiol 1994;73:407-9.  Back to cited text no. 18
Harrison LH Jr., Kisslo JA Jr., Sabiston DC Jr. Extraction of intramyocardial foreign body utilizing operative ultrasonography. J Thorac Cardiovasc Surg 1981;82:345-9.  Back to cited text no. 19
Regoli F, Caputo M, Conte G, Faletra FF, Moccetti T, Pasotti E, et al. Clinical utility of routine use of continuous transesophageal echocardiography monitoring during transvenous lead extraction procedure. Heart Rhythm 2015;12:313-20.  Back to cited text no. 20
Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, et al. Guidelines for performing a comprehensive transesophageal echocardiographic examination: Recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 2013;26:921-64.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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