Abstract 18034: Intracardiac Bullet: To Fish It Out or Let Love Take the Shot!

Background: Gunshot wounds cause catastrophic injuries. When bullets embolize to heart, without penetrating cardiac injury, optimal management remains unclear.

Case: 25 year old male, presented after multiple gunshot wounds (GSW). On exam, perirectal GSW, 3 GSWs to right thigh and 2 GSW to left thigh noted. Lungs CTA bilaterally, CVS normal S1, S2. CTA chest showed Infra renal IVC injury and large retroperitoneal hematoma. (1,2). ECHO revealed a bullet in the dependent part of right atrium, abutting the tricuspid valve (3). No chest injury noted, suggesting migration of bullet from IVC, following the trajectory of venous return to right atrium. He underwent IVC patch repair. Percutaneous approach was unsuccessful to snare the bullet using 8-mm and 14-mm triloop snare, 15-mm gooseneck snare (4), bronchial forceps (5) and balloon. Multidisciplinary team decided to abandon further percutaneous or surgical extraction attempts as the bullet firmly lodged in sub-tricuspid chordo papillary apparatus with no valvular dysfunction.

Discussion: In hemodynamically stable patient with intracardiac bullet, there is no standard treatment approach. 65% of bullets entering vena cava, migrate and lodge in chordo papillary apparatus or trabeculations. Low risk percutaneous extraction approaches have gained popularity, with about 50% success. When percutaneous extraction fails, clinicians face a critical decision to observe or perform open sternotomy extraction. Numerous case reports support observation only approach. This patient has done well with observation, suggesting non-operative initial management is reasonable in hemodynamically stable patient with intracardiac bullet.