By A Long Shot: Venous Bullet Embolization to the Heart
Authors: Elaine Huang, MD; Michael Crawford, MD; Laura Padilla-Carrasquillo MD; Rohan Samson, MD
Introduction:
Direct penetrating cardiac injuries from gunshot wounds have been well documented and commonly lead to life threatening conditions such as cardiac tamponade. However, reported cases of indirect cardiac involvement from firearms are rare but can occur from peripheral embolization of bullets or bullet fragments into the heart or pulmonary vasculature. Here, we present a case of a young man who sustained a gunshot wound (GSW) from a shotgun to his left upper extremity (LUE) with a subsequent bullet fragment noted within the right ventricle (RV) on imaging.
Case presentation:
A 25-year-old man presented following a GSW to his LUE. He was struck by numerous small lead pellets from the spray of the shotgun. His only complaint was pain localized to the GSW. Initial chest X-ray and computed tomography (CT) revealed multiple pellets in his LUE, one in his neck, and one that seemed to be localized within the RV or pericardium. He had no entry wounds to his anterior chest. Transthoracic echocardiogram (TTE) was able to confirm the presence of a pellet within the RV trabeculae along the free wall. There was no pericardial effusion or other significant abnormalities. Electrocardiogram was unremarkable and troponin I levels were normal. Serial imaging with TTE showed no change in position of the pellet or development of pericardial effusion. Given the stability, no surgical intervention or endovascular retrieval was done. Antibiotics were recommended for bacterial endocarditis prophylaxis.
Discussion:
Firearm injuries are relatively common, with over 67,000 people affected annually, but bullet embolization to the heart is a rare occurrence. The small pellet-like projectiles ejected from a shotgun have the potential to embolize from the peripheral venous system into the cardiac chambers. While the vascular entry point for our case was unclear, the absence of any entry wounds to the thorax led to the presumption that the pellet originated from a vein in the LUE.
Conclusion:
Venous bullet embolization to the heart most commonly occurs in the right sided chambers and with the potential to embolize to the pulmonary tree. Recommendations for management vary and each have their associated risks and benefits. In a patient with an embedded bullet fragment with low risk of embolization seen on serial imaging, observation is a reasonable management choice.
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