INTRA CARDIAC BULLET WITH INTRA VASCULAR PULMONARY EMBOLIZATION Case Report with literatures Review Assistant prof. Abdulameer M. Hussein Baghdad College of medicine Al-Shaheed Ghazi Al-Harreri Hospital

INTRODUCTION  foreign bodies have entered the cardiovascular system and embolized in various directions, causing confusion on the part of the examining surgeon[1].  So in the trauma setting, penetrating vascular injuries secondary to gunshot wounds need to be addressed promptly and carefully, by identifying the entry and exit site, the pathway of injury can usually be determined[2].  Bullet embolism to the pulmonary artery is a rare complication of penetrating gunshot traumas, an embolism to arterial system is more common than a venous embolism [3,4 ].

Case report Middle age female 44ys presented to the emergency ward as a case of bullet injury to the abdomen. She was admitted directly after resuscitation to the theater. In the general surgery department explorative laparotomy through midline incision done and the findings were: 1. Hemoperitoneum. 2. Two perforations of the stomach. 3. Tear of the left lobe of the liver. 4. Injury to the diaphragm. 5. Two tube drain were left in the abdomen. 6. Left side hemothorax managed by left side tube thoracostomy which drained 500cc of blood.

 1 st postoperative day was smooth  Drain was 100cc,  Chest x-ray showed bullet overlapping cardiac shadow.  So ECG and echocardiography had been done which was normal?  3 rd postoperative day  no more drain,  chest x-ray was clear  tube drain and tube thoracostomy removed.

 5 th postoperative day  New chest x-ray was done which showed new collection in the right pleural space.  So another chest tube inserted in the Rt. side 5 th intercostals space, midaxillary line, and 600cc of serosanguinous fluid was drained.  Removal of tube thoracostomy was two days later. In the first follow up visit (28 days) from the day of injury: Chest C-T scan showed a high density foreign body impacted in the apex of interventricular septum of the heart, and no other abnormality.

The Patient refused the advice for surgery, so we recommended follow up for her  In second follow up visit after one month:  Chest x-ray …. No change in bullet position.  New echocardiography study had done showed echogenic linear shadow in the region of the right ventricular apex near the septum and no other abnormality.  In third follow up visit after 5 months:  Patient was dyspnoeic, tachypneic, and tachycardia.  Chest x-ray showed bullet shadow seen at the right mid zone of the lung.  Admission and conservative management arranged.  New chest C-T scan showed irregular outline metallic density was seen at the right middle lobe pulmonary artery branch.

Fig. ( 1 ): Chest x- ray showing bullet overlapping cardiac shadow. (1 st post operative day ),with left side thoracostomy tube

Fig.( 2) Ct-scan shows high density F.B. impacted in the apex of interventricular septum of the heart

Fig. ( 3 ): CXR showing bullet migrated to the Rt. Mid zone

Fig. ( 4 ): C – T scan showing bullet migrated to the Rt. middle lobe pulmonary artery branch

Surgical procedure Under general anesthesia and double lumen endotracheal tube.  Right posterolateral thoracotomy through 5 th intercostals space.  we identified the bullet by palpation in the middle lobe pulmonary artery branch.  Small pneumonotomy and arteriotomy incision was performed directly over this site to enable the bullet to be retrieved using forceps.  Pneumonotomy and arteriotomy incision closed.  Hemostasis,  Apical and basal tube thoracostomy,  Closure in layers.  Smooth postoperative period.  We administered anticoagulant therapy for prophylaxis of pulmonary thromboembolism.

Fig. (5): Postoperative [ thoracotomy ] CXR

Discussion Penetration of the thorax may result in an injury to the heart,or invisible penetration sites with distal emobilization, a high mortality has resulted from lack of control of the vascular entrance site. Reasons for removing a bullet embolus to the heart include  Prevention of bacterial endocarditis,  Recurrent pericardial effusion,  Myocardial irritability,  Interference with the valvular mechanism of the tricuspid valve  Anxiety neurosis

 When bullet enters a vessel, it may cause  Hemorrhage.  Thrombosis.  Sepsis.  Erosion or vascular occlusion.  The ideal surgical strategy should be individualized to the patient.  Authors still have different ideas on treatment of venous bullet embolism, when the patient is asymptomatic most authors recommend conservative methods [5, 6].  Removal of the bullet with fluoroscopic guidance using a basket catheter is another procedure that may have great value when used in suitable cases [7].

 Percutaneous extraction of the embolized bullet may also be tried. If possible, this type of extraction  can be performed under local anesthesia, thus  avoiding the risk of mortality and morbidity relating to surgery. Complications:  Movement of the bullet to wedge position and intimal damage, may occur.  Adhesion of the bullet to the pulmonary arterial wall or thrombus formation will affect the successful removal of the bullet [8, 9].

Intravascular migratory bullet may penetrate a vascular or cardiac lumen by direct energy propulsion or may later erode into the vessel [10]. During the follow up of the presented case, we noticed symptoms and sign of pulmonary embolism, plain chest x-ray showed that was a change in the position of bullet which was proved by chest C-T scan later on in the right middle lobe pulmonary artery branch.

Preoperative identification of the exact location of the bullet is very important in planning management, since remobilization of a missile may continue to occur [5, 6, 14]. Tow important factors determine the final destination of the bullet, these factors are  Kinetic energy.  Diameter of missile [12,13] The missile may embolize secondary to positional changes combined with the weight of the a bullet and gravity, vascular anatomy and flow dynamics also affect the destination, moving from the heart to the pulmonary artery, from one pulmonary artery to the opposite pulmonary artery, or even down the inferior vena cava [2, 15, 16]

So surgeon must keep in mind the possibility of the bullet dropping to the opposite pulmonary artery when the patient positioned for thoracotomy. Following isolation of embolized missile, operative removal is in general recommended.

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