Symbas P N, Vlasis-Hale S E, Picone A L, Hatcher C R
Department of Surgery, Emory University School of Medicine, Atlanta, Georgia.
Ann Thorac Surg. 1989 Aug;48(2):192-4. doi: 10.1016/0003-4975(89)90066-0.
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.
回顾了1968年至1987年在格雷迪纪念医院接受治疗的24例心脏内留有异物的患者记录。其中22例异物直接损伤心脏后留存于心内，其余2例是子弹损伤体静脉后异物进入心脏。心脏损伤后即刻，22例患者中7例出现心脏压塞（3例同时伴有血胸），11例出现血胸，5例无症状，1例处于休克状态。7例患者接受了急诊开胸手术；3例取出了子弹，但其余4例未找到子弹。另外17例患者以及急诊开胸手术中未找到子弹的4例患者，胸部X线片怀疑有异物存留，经心脏荧光透视或心血管造影得以证实。8例留有子弹的患者接受了择期手术；7例取出了子弹，1例子弹仍嵌顿于右心室间隔。除1例发生心包炎外，所有10例行异物切除术的患者均康复且无并发症，全部患者随访长达17年。14例心脏内留有异物的患者均无与子弹相关的心脏症状，随访长达15年。该经验表明，对于心脏内留有口径为.38或更小子弹的患者，应根据患者的临床病程和子弹位置进行个体化处理，且在部分患者中，心脏内留存的子弹耐受性良好。
