Ann Thorac Surg 2006;82:737-739
© 2006 The Society of Thoracic Surgeons
Case report
Late Mitral Valve Regurgitation After Bullet Wound to the Heart
Stéphane Aubert, MD, MS*,
Olivio Souza Neto, MD,
Amit Pawale, MD, MRCS,
Gilles D. Dreyfus, MD, PhD
Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Harefield, Middlesex, United Kingdom
Accepted for publication November 22, 2005.
* Address correspondence to Dr Aubert, Department of Cardiothoracic Surgery, Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End Rd, Harefield, Middlesex, UB9 6JH United Kingdom (Email: stephaneaubert{at}yahoo.fr).
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Abstract
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We report a very rare case of mitral valve injury due to gunshot, presenting 1 year after the incident. The bullet had traversed through the chest and had gone through the anterior mitral leaflet to reside in the pericardium. The first clinical presentation was unremarkable and the patient became symptomatic 1 year later. We operated on him for severe mitral valve regurgitation, repairing the hole in the anterior mitral leaflet. The 1-year follow-up showed a good symptomatic and echocardiographic success.
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Introduction
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Penetrating cardiac injuries caused by gunfire constitute the most lethal forms of cardiothoracic trauma with their potential fatality. The heart lesions encountered in such cases are variable and sometimes surprising [1–3]. Usually patients present with hemorrhagic shock and cardiac tamponade in a collapsed state. Only prompt resuscitation and early surgical intervention can provide a favorable outcome [4]. However the first presentation of a bullet wound to the heart can be a patient who is hemodynamically stable with an unremarkable cardiovascular examination presenting several years later.
A 31-year-old man known to be free of heart disease had a gunshot in his right upper chest. At the first clinical presentation he was hemodynamically stable without any hemorrhagic shock or tamponade. The electrocardiogram was unremarkable. The roentgenogram showed a pneumo-hemothorax and a bullet was found in the area of the heart (Fig 1). A noncontrast scan was performed showing a linear cloud of density in the right anterior lung marking the passage of the bullet. The bullet had partly hit a rib and then traversed through the lung. It was sitting just in front of the descending thoracic aorta to the left of the midline, somewhere in the region of the posterior recess of the pericardium (Fig 2). He underwent a transesophageal echocardiography under general anesthesia, revealing no myocardial abnormalities, no pericardial effusion, and a mild mitral regurgitation, which at that time was believed to be negligible. One year later he returned to the hospital for breathlessness and fatigue. The echocardiography revealed severe mitral regurgitation, including two jets, with increased end-systolic diameter of the left ventricle (39 mm). The indication for mitral valve repair was straightforward.
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Fig 1. Left: chest roentgenogram showing a bullet in the area of the heart. Right: the bullet after retrieval.
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Fig 2. Computed tomographic scan of the chest showing subcutaneous emphysema, passage of the bullet through the lung, and right-sided hemothorax. The bullet is residing in front of the aorta.
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After a median sternotomy and opening the pericardium, there were severe adhesions like re-do sternotomy patients, which indicated that there had been a pericardial effusion or at least a foreign body that had created this intense reaction. After having freed these adhesions, some more dense adhesions were dissected free at the inferior aspect of the left ventricle, and the bullet was found in the outer layers of the free wall of the left ventricle covered by the pericardium. The bore of the bullet was 4 mm. The heart was found to be grossly dilated. After opening the left atrium in the Sondergaard's sinus, the analysis of the mitral valve revealed the following lesions: there was a segmental prolapse of P3 related to a ruptured chordae at the free margin of P3, and there was a significant hole approximately 1 cm2 in A2 (Fig 3).
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Fig 3. Left: the hole in the anterior mitral leaflet. Right: the autologous pericardial patch closing the hole.
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The mitral valve lesions were treated as follows: an autologous patch of pericardium was tailored and secured to the hole in the anterior leaflet with a running 5-0 Cardionyl suture (Fig 3). As far as the posterior leaflet prolapse (above 7 to 8 mm) was concerned, the posterior head of the posterior papillary muscle was split from the anterior head. Then the tip of this posterior head was brought down into the ventricle [5] and secured to the anterior head with autologous pericardial patches by two 4-0 Cardionyl sutures. The dilated annulus was corrected by implantation of a 30-mm Carpentier Edwards physiological ring. Intraoperative transesophageal echocardiography showed excellent valve function with no regurgitation. One year after surgery the patient had fully recovered, was asymptomatic, and had returned to work. The patient's last echocardiogram showed no mitral valve regurgitation. The end-systolic diameter of the left ventricle was decreased (32 mm), and the mean diastolic gradient across the mitral valve was 2.4 mm Hg.
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Comment
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This is the first report of a penetrating bullet wound to the heart resulting in a lesion of the mitral valve requiring mitral repair 1 year later. McClurken [2] described a case of transcardiac gunshot wound that was recognized 48 years later, but this patient was in tamponade at the first clinical presentation and the mitral valve was not involved. We did not find any hemopericardium, which was probably drained in the right pleural cavity. The hole of the anterior leaflet could have been a lesion related to healed endocarditis. However, the patient never had any episode of fever since the gun shot incident. We relate this lesion most likely to the passage of the bullet. The chordal rupture according to the free edge of P3 was probably a consequence of the passage of the bullet in the subvalvular apparatus. For the education of cardiothoracic surgeons, it is important to stress that we have to carefully follow-up the patients after a gunshot to the chest, even if the first clinical presentation is unremarkable as further change is possible.
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References
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- Bali HK, Vijayvergiya R, Banarjee S, Kumar N. Gunshot injury of the heartan unusual cause of acute myocardial infarction. Tex Heart Inst J 2003;30:158-160.[Medline]
- McClurken JB, Hammer WJ, Lin BJ. Transcardiac gunshot wound recognized forty-eight years later J Thorac Cardiovasc Surg 2003;126:293-295.[Free Full Text]
- Wainsztein N, Mautner B. A bullet in the heart Circulation 1999;100:1361.[Free Full Text]
- Johnson SB, Nielsen JL, Sako EY, Calhoon JH, Trinkle JK, Miller OL. Penetrating intrapericardial woundsclinical experience with a surgical protocol. Ann Thorac Surg 1995;60:117-120.[Abstract/Free Full Text]
- Dreyfus GD, Bahrami T, Al Ayle N, Mihealainu S, Dubois C, de Lentdecker P. Repair of anterior leaflet prolapse by papillary muscle repositioninga new surgical option. Ann Thorac Surg 2001;71:1464-1470.[Abstract/Free Full Text]
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Abstract
Introduction
