Christian-Colón Gustavo, Figueroa-Martínez Gabriel, Rodriguez-Reyes Derick, López-Alvarado Raysa, Cruz-Centeno Nelimar, De Soto-Cordero Nydia
Surgery, Ponce Health Sciences University, Ponce, PRI.
General Surgery, University of Puerto Rico, Medical Sciences Campus, San Juan, PRI.
Cureus. 2025 May 17;17(5):e84268. doi: 10.7759/cureus.84268. eCollection 2025 May.
Penetrating cardiac injuries (PCI) from gunshot wounds are among the most fatal forms of trauma, with prehospital mortality rates exceeding 90%. While the right ventricle is most commonly affected due to its anterior location, retained intracardiac projectiles are rarely encountered and pose significant management challenges. Cardiac tamponade, though potentially fatal, can sometimes provide a protective mechanism by limiting hemorrhage. The decision to surgically remove retained bullets remains controversial, particularly in hemodynamically stable patients. We report the case of a 51-year-old male who sustained multiple gunshot wounds, including a thoracic injury with an 8 mm bullet fragment retained in the right ventricle. On arrival, the patient was hemodynamically stable despite imaging revealing a pericardial effusion and a sternal fracture. A median sternotomy with pericardiotomy was performed, revealing a right ventricular epicardial wound without active bleeding. Due to the absence of cardiopulmonary bypass, the intracardiac bullet was not removed. The patient received prophylactic heparin and was monitored with imaging and serial exams. He was discharged without complications. This case highlights a rare presentation of PCI without overt tamponade physiology, despite the presence of a pericardial effusion. The patient remained stable throughout hospitalization, supporting the hypothesis that tamponade can temporarily contain hemorrhage. Conservative management of retained intracardiac projectiles may be appropriate in select patients, particularly when the projectile is embedded in the trabeculated myocardium and the risk of embolization is low. Literature suggests that long-term outcomes can be favorable with nonoperative management in stable cases. This case reinforces the importance of rapid surgical intervention for PCI, even in stable patients, and supports individualized, conservative management of retained cardiac projectiles in the absence of cardiopulmonary bypass. Further research is needed to define standardized protocols for managing intracardiac foreign bodies in trauma.
枪伤导致的穿透性心脏损伤（PCI）是最致命的创伤形式之一，院前死亡率超过90%。虽然右心室因其靠前的位置最常受到影响，但心腔内残留弹丸很少见，且带来重大的处理挑战。心脏压塞虽然可能致命，但有时可通过限制出血提供一种保护机制。手术取出残留子弹的决定仍存在争议，尤其是在血流动力学稳定的患者中。我们报告一例51岁男性，他遭受多处枪伤，包括胸部损伤，右心室内保留一枚8毫米子弹碎片。入院时，尽管影像学显示有心包积液和胸骨骨折，但患者血流动力学稳定。实施了正中胸骨切开术并心包切开，发现右心室心外膜有伤口但无活动性出血。由于未进行体外循环，心腔内的子弹未取出。患者接受了预防性肝素治疗，并通过影像学和系列检查进行监测。他出院时无并发症。该病例突出了PCI一种罕见的表现，即尽管存在心包积液，但无明显的压塞生理学表现。患者在整个住院期间保持稳定，支持了压塞可暂时控制出血的假说。对于某些患者，特别是当弹丸嵌入小梁心肌且栓塞风险较低时，对心腔内残留弹丸进行保守处理可能是合适的。文献表明，稳定病例的非手术治疗长期预后可能良好。该病例强化了即使在稳定患者中对PCI进行快速手术干预的重要性，并支持在无体外循环情况下对心腔内残留弹丸进行个体化、保守处理。需要进一步研究来确定创伤中心腔内异物处理的标准化方案。
