Missiles in the heart.

The records of 24 patients who had a missile retained in the heart and who were treated at Grady Memorial Hospital from 1968 to 1987 were reviewed. In 22, the missile lodged in the heart after its direct injury and in the remaining 2, after the bullet injured a systemic vein. Immediately after the cardiac injury, 7 of the 22 patients were seen with cardiac tamponade (3 also had hemothorax), 11 were seen with hemothorax, 5 were asymptomatic, and 1 was in shock. Seven patients underwent emergency thoracotomy; the bullet was removed in 3, but in the remaining 4 patients, it was not located. In the other 17 patients and in the 4 in whom the bullet could not be found during emergency thoracotomy, the diagnosis was suspected from the chest roentgenograms and confirmed by cardiac fluoroscopy or angiocardiography. Eight patients with retained bullets underwent elective operation; the bullet was removed from 7 and in 1 it was left embedded in the right ventricular septum. All 10 patients who underwent excision of the missile recovered without complication except 1 in whom pericarditis developed, and all were followed for up to 17 years. All 14 patients with a retained missile in the heart had no cardiac symptoms referable to the bullet and were followed for up to 15 years. This experience suggests that the management of patients with a bullet of .38 caliber or smaller that is retained in the heart should be individualized according to the patient's clinical course and the site of the bullet and that in select patients, bullets left in the heart are tolerated well.