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J Thorac Cardiovasc Surg 2003;126:293-295
© 2003 The American Association for Thoracic Surgery

Brief communication

Transcardiac gunshot wound recognized forty-eight years later

James B. McClurken, MDa,*, William J. Hammer, MDb, Bradford J. Lin, MDb

a The Divisions of Thoracic and Cardiovascular Surgery, Abington Memorial Hospital and Temple University Hospital, Abington and Philadelphia, Pa, USA
b Division of Cardiology, Abington Memorial Hospital and Chestnut Hill Hospital, Abington and Philadelphia, Pa USA

Abington and Philadelphia, Pa Received for publication November 13, 2002; accepted for publication December 16, 2002.

* Address for reprints: James B. McClurken, MD, Suite G28, Levy Medical Plaza, 1235 Old York Rd, Abington, PA 19001 USA

Key Words: 5 • 17 • 18


James B. McClurken


Current treatment for transcardiac gunshot wounds (GSWs) includes expedient surgical repair. We performed coronary revascularization on a veteran of the Korean conflict who had been shot in the left axilla. The bullet was retrieved 2 days after the GSW through a superficial right chest wall incision, and the patient was told the missile "missed his heart by an inch." During the recent revascularization, plug-like calcific scars proved entrance at the lateral left atrium base of the appendage and exit at the right atrium midlateral wall. Thus this might represent the first reported survivor of a transcardiac GSW without direct repair.

Clinical Summary

A 70-year-old hypertensive man had worsening stress test results. Catheterization revealed a 35% lesion of the left main coronary artery, a 90% blockage of the ostium of the left anterior descending artery (LAD), and a 60% mid-LAD blockage involving a large diagonal branch with multiple 30% to 40% lesions involving all other vessels. Echocardiography revealed left ventricular hypertrophy, mild mitral regurgitation, mild tricuspid regurgitation, and normal left ventricular function. Neither an atrial nor a ventricular septal defect was seen.

The history was significant for a GSW to the chest. The patient stated he was wearing a flak jacket while on patrol in June 1953, when he was hit 7 times by bullets to the torso. The flak jacket deflected 6 of the bullets, but a seventh entered the left axilla (Figure 1, A). Because of the hostile fire, a medic dressed the wound and informed the patient he would have to walk 3 miles to the nearest mobile army surgical hospital. On arrival, the patient collapsed into the tent. Resuscitation included 3 pints of blood; he described subcutaneous emphysema of the entire chest wall.



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  		Figure 1. A, View of left axilla showing surgical scars. B, Right lateral chest wall.

 
The patient was then transferred to Tokyo, where a US military surgical team performed a lateral thoracic incision (Figure 1, B) and removed the bullet from superficial tissue, stating the flak jacket prevented the exit wound. He was given the bullet (Figure 2). Over the ensuing 3 days, he described daily thoracentesis for a pint of bloody fluid. He subsequently recovered.



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  		SFigure 2. Bullet removed from left axilla in 1953.

 
With this history, preoperative computed tomographic scanning demonstrated calcific areas along the left lateral and right lateral pericardium; no foreign body was seen (Figure 3). The trajectory aligns with the left axillary and right lateral chest wall wounds. On November 17, 2001, the patient underwent coronary artery bypass grafting twice with the left internal thoracic artery grafted to the LAD and a saphenous vein graft to the diagonal artery. At pericardiotomy, generalized adhesions were encountered, as was a calcific plug-like reaction where the pericardium was fused to the base of the left atrial appendage, for a diameter of about 0.5 cm. A similar finding was noted at the right atrial lateral wall with 1-cm plugging. His recovery after coronary artery bypass grafting was uneventful.



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  		Figure 3. Computed tomographic scans.

 
Discussion
We postulate that the small-caliber (approximately 0.30) full-metal jacket military round did not deform, deflect, or tumble, and it caused small holes in low-pressure chambers. Tamponade and hypotension ensued and was later treated with blood infusion. Delayed thoracentesis implies ongoing oozing from the pericardial-atrial holes. The bullet likely traversed the atrial septum obliquely, and the atrial septal defect appears to have healed.

A review of the literature1-4 fails to reveal any survivor of a transmediastinal GSW without prompt direct surgical repair. Although we are certainly not advocating conservative management of transmediastinal GSWs, survival might be possible (rarely).

References

  1. Johnson SB, Nielsen JL, Sako EY, Calhoon JH, Trinkle JK, Miller OL. Penetrating intrapericardial wounds: clinical experience with a surgical protocol. Ann Thorac Surg. 1995;60:117–121[Abstract/Free Full Text]
  2. Wall MJ Jr, Mattox KL, Chen CD, Baldwin JC. Acute management of complex cardiac injuries. J Trauma. 1997;42:905–912[Medline]
  3. Moreno C, Moore EE, Majure JA, Hopeman AR. Pericardial tamponade: a critical determinant for survival following penetrating cardiac wounds. J Trauma. 1986;26:821–825[Medline]
  4. Kulshrestha P, Das B, Iyer KS, Sampath KA, Sharma ML, Rao IM, et al. Cardiac injuries–a clinical and autopsy profile. J Trauma. 1990;30:203–207[Medline]



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