Ann Thorac Surg 2004;77:1083-1085
© 2004 The Society of Thoracic Surgeons
Case report
Intracardiac shrapnel in a polytraumatized child
Hrvoje Gasparovic, MDa*,
Ranka Stern-Padovan, MD, PhDb,
Stipe Batinica, MD, PhDa,
Dalibor Saric, MDa,
Ivan Jelic, MD, PhDa
a Department of Cardiac Surgery, University Hospital Rebro, Kispaticeva 12, Zagreb, Croatia
b Department of Radiology, University Hospital Rebro, Zagreb, Croatia
Accepted for publication April 8, 2003.
* Address reprint requests to Dr Gasparovic, Vinkoviceva 13, 10000 Zagreb, Croatia
e-mail: hgasparovic{at}yahoo.com
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Abstract
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Penetrating cardiac trauma is a life-threatening condition and presents a therapeutic challenge for the surgeon. Additional multiple organ-system injuries, as are common in the setting of war, further complicate the management of such patients. We present the case of a 9-year-old girl who sustained multiple injuries from an unexploded artillery shell, resulting in a retained intracardiac shrapnel. Her cardiac pathology consisted of a shrapnel located in the interventricular septum accompanied by a pneumopericardium and a right-sided hemopneumothorax. The presentation and management of this patient are the subjects of this report.
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Introduction
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A penetrating wound to the heart is often catastrophic for the patient. Prompt diagnosis and aggressive resuscitative measures are critically important. The management of retained intracardiac missiles in hemodynamically stable patients remains controversial. The decision-making process in electing an appropriate course of management should be based on the characteristics of the individual case.
We present a polytraumatized 9-year-old girl admitted to the emergency department in hemorrhagic shock secondary to multiple shrapnel injuries. The injury was caused by an unexploded artillery shell, a sad remnant of the recent war in Croatia. She was found to have a penetrating head wound with an intracranial shrapnel fragment, a penetrating right thoracic wound with a hemopneumothorax, a penetrating abdominal injury with perforations of the small intestine, a multifragmentary fracture of the right distal humerus, and explosive injuries of the soft tissues of the right thigh and right foot. Standard chest computed tomography (CT) also showed an intracardiac shrapnel accompanied by a pneumopericardium. Initial management consisted of volume repletion, placement of a right chest tube, and exploration of the abdominal cavity, followed by resection of the damaged ileum and removal of a foreign body as well as by internal fixation of the fracture of the right humerus. These measures promptly resolved her hemodynamic instability. This report focuses on her penetrating cardiac injury.
A multislice chest CT was obtained to precisely locate the foreign body within the heart. The axial images traced the path of the fragmented object as it penetrated the right thoracic wall causing an intrapulmonary hematoma and right hemopneumothorax, as well as a pneumopericardium: the location of the shrapnel was documented within the interventricular septum (Fig 1). The sagittal projection clearly shows a pneumopericardium and a foreign intracardiac body (Fig 2). The CT images were processed using 3–D volume-rendering techniques. The image thus obtained shows the entry point of the shrapnel on the right ventricular surface (Fig 3).
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Fig 1. Axial computed tomography image showing the path of the thoracic shrapnel. A rib fracture (1), intrapulmonary hematoma (2), and foreign object located within the interventricular septum (3) are seen.
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Fig 3. Entry point of the intracardiac missile (arrow) illustrated on a three-dimensional volume-rendered computed tomography image.
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The patient exhibited no further signs of cardiac distress throughout her hospital stay. Echocardiograms (echo) were obtained daily to closely monitor the patient's cardiac performance and to identify early possible complications of her penetrating thoracic injury. No pericardial effusion was documented, and the ventricular performance was not impaired at any time. Valvular function was maintained and her echo was unremarkable. We therefore opted for a conservative approach in the management of this penetrating cardiac injury. The patient was discharged from the hospital 32 days after her initial trauma.
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Comment
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Penetrating injury of the heart is an ominous condition with a significant potential for death. Prompt intervention is critical. Volume repletion and drainage of the pleural and pericardial spaces have been advocated. The indications for immediate surgical intervention are well established: hemorrhagic shock, cardiac tamponade, and injury to the great vessels [1]. Retained intracardiac missiles are sometimes seen in association with penetrating injury to the heart. These projectiles may also be the aftermath of embolizations from a peripheral site where the foreign body entered the venous system [2]. The management of a hemodynamically stable patient with an intracardiac foreign body remains controversial, and the approach should be individualized [2]. Projectiles within the heart may be located freely within a cardiac chamber, in which case they may cause embolization. An intracardiac missile may also be embedded within the myocardium. However, the possibility of subsequent mobilization and embolization of the foreign body cannot be ruled out. All of the observed injuries in our case were caused by an unexploded artillery shell, with all the characteristics of a high-velocity projectile seen in wartime trauma. The patient initially presented with severe hemodynamic compromise. Restoration of intravascular volume and drainage of the right hemopneumothorax stabilized her cardiac status. Her intra-abdominal injury was then addressed. In contrast to wartime polytrauma, civilian penetrating thoracic injuries tend to be caused by missiles with less kinetic energy, typically originating from handguns and hunting rifles, and therefore have a more favorable overall outcome [3].
Axial and sagittal CT evaluation of our patient's penetrating thoracic wound found an intracardiac shrapnel within the interventricular septum. The 3–D CT reconstruction image indicated that the shrapnel entered the heart from the right ventricular side. Frequent echo monitoring averted posttraumatic sequelae such as delayed cardiac tamponade, interventricular communication, or valvular abnormalities. Electrocardiographic examinations showed no rhythm anomalies secondary to a retained intracardiac embolus. Our patient was a polytraumatized child whose associated injuries required more urgent interventions than did her cardiac condition. Considering that her cardiac pathology was benign, we opted for a conservative management approach. The risks of such a therapeutic option must be considered, and a high index of suspicion should be maintained for the development of complications of an intracardiac projectile. These include valvular insufficiency, intracardiac shunts, conduction abnormalities, distal embolizations, late pericarditis, coronary artery disease, and endocarditis [2, 4, 5].
A retrospective analysis by Symbas et al of 14 of 24 patients with intracardiac missiles who were managed without surgical intervention found that the patients tolerated the object well for up to 15 years of follow-up [6]. The remaining 10 underwent surgical extraction of the projectile [6]. Identifying and removing the intracardiac missile may not always be simple and, in fact, the object may elude intraoperative exploration [6]. Our opinion, corroborated by this case, is that in a patient without symptoms related to the intracardiac projectile, a conservative approach with regular follow-up examinations is acceptable. However, the development of any of the aforementioned complications requires prompt surgical intervention.
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References
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- Kish G., Kozloff L., Joseph W.L., Adkins P. Indications for early thoracotomy in the management of chest trauma. Ann Thorac Surg 1976;22:23-28.[Abstract]
- Gandhi S.K., Marts B.D., Mistry B.M., Brown J.W., Durham R.M., Mazuski J.E. Selective management of embolized intracardiac missiles. Ann Thorac Surg 1996;62:290-292.[Abstract/Free Full Text]
- Jebara V., Saade B. Penetrating wounds to the heart: a wartime experience. Ann Thorac Surg 1989;47:250-253.[Abstract]
- Seipelt R.G., Vazquez-Jimenez J.F., Messmer B.J. Missiles in the heart causing coronary artery disease 44 years after injury. Ann Thorac Surg 2000;70:979-980.[Abstract/Free Full Text]
- Karmy-Jones R., Yen T., Cornejo C. Pericarditis after trauma resulting in delayed cardiac tamponade. Ann Thorac Surg 2002;74:239-241.[Abstract/Free Full Text]
- Symbas P.N., Vlasis-Hale S.E., Picone A.L., Hatcher C.R., Jr Missiles in the heart. Ann Thorac Surg 1989;48:192-194.[Abstract]
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Abstract
Introduction
