A 19-year-old man received a gunshot injury to the heart.

A 19-year-old man received a gunshot injury to the heart. Transthoracic echocardiography was unable to localize the bullet fragment, whereas transesophageal echocardiography localized the bullet fragment in the posteroseptal wall at the base of the posteromedial papillary muscle. (Chest 1994; 106:299-300)

TEE=transesophageal echocardiography

Echocardiography may be intrust with an agencyed to asses patients with penetrating chest trauma when cardiac involvement is suspected and has been shown to change into the time to surgical intervention and thus mould the mortality risk.(1)(2) A prior report hints that transesophageal echocardiography (TEE) may be superior to transthoracic echocardiography in defining the expanse of cardiac trauma from a gunshot wound(3) In this case report, we describe a patient who received a gunshot damage to the heart. Transesophageal echocardiography accurately located and characterized the intracardiac bullet fragment, whereas transthoracic echocardiography failed to do so

CASE REPORT

A previously healthy 19-year-old man was shooter at close range in the midst of an argument across the ownership of a small quantity of crack cocaine. The assailant occupyed a 0.22 caliber pistol. A single missile was fired. It penetrated the patient's left anterior thorax and did not exit. The patient sink ed to the ground unconscious. His friends rushed him to the University of southward Alabama Medical Center within 10 min of the shooting.

The patient was unconscious in succession arrival at the emergency ward. His vital signs were as follows: relations pressure, 60/30 mm Hg; measured [i]or[/i] regular beat rate, 152 beats/min; respiratory rate, 22/min; and temperature, 374[degrees]C (rectal). His skin was frosty and clammy. An entry pain was noted in the fifth intercostal space, just lateral to the midclavicular line. be deriveds of the heart examination were normal exclude for the rapid rate and muffl heart hales The lung examination showed decreased breath perfects in the left lung base. There was no jugular venous distention. Arterial oscillations were weak throughout. A portable chest radiograph showed a 02X05-cm density (bullet fragment) within the confines of the heart shadow, on the contrary was unable to document an intracardiac localization. There was a left pleural effusion. Specific characterization and localization of the bullet fragment was not achieved.

Following infusion of 5 L of lactated Ringer's solution, the patient's kin pressure increased to 105/60 mm Hg and the heart rate decreased to 125 beats/min. Transthoracic (M-mode and two-dimensional) echocardiography was performed in the unforeseen occasion ward (Fig 1). A diffuse unattached echo-dense artifact was observ in the left ventricular cavity in the apical four-chamber view. The patient underwent push thoracotomy.

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The bullet had lacerated the left anterior pleura, inscribeed the mediastinum, and penetrated the pericardium and ventricular myocardium. Precise localization was not achieved. There was no exit detriment The surgeon elected to oversew the cardiac entrance wound rather than extract the bullet Following infusion of 4 U of packed RBC the posterity pressure rose to 110/70 mm Hg and the heart rate decreased to 118 beats/min. During the postoperative period, transthoracic echocardiography was repeated. There was no change from the preoperative studious mood except for the development of a small well-circumscribed area of apical akinesis. The bullet fragment by se still could not be located. Transesophageal echocardiography was performed using an ultrasonograph (Hewlett-Packard Sonos 1000) with a monoplane probe and clearly located the bullet fragment (Fig 2) Findings from the remainder of the postoperative period were uneventful

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DISCUSSION

Transthoracic (primarily two-dimensional) echocardiography has been used with increasing common occurrence in patients with penetrating chest trauma to determine whether cardiac involvement is present(1)(2) Transthoracic echocardiography is capable of confirming the port or absence of a pericardial effusion in principally cases, but its efficacy in characterizing myocardial damage from penetrating trauma and localizing intracardiac foreign bodies has not been established.(1)(2) The ability to obtain a highquality echocardiographic consideration in patients with possible penetrating cardiac trauma may be impeded by means of the absence of an adequate echocardiographic window to be ascribed to chest wall trauma or the neighborhood of bandages.(1)(2) In this case, transthoracic echocardiography was unable to locate the bullet fragment. simply the diffuse echo-dense artifact from the bullet fragment was visualized.

Transesophageal echocardiography is capable of recording solution cardiac structures and obviates the ne to find an adequate echocardiographic window to obtain cardiac images. It is superior to transthoracic echocardiography in the assessment of right heart buildings and in the detection of intracardiac switchs Biplane TEE is capable of accurately interrogating the proximal and distal aorta. Our experience in this case moves that TEE is superior to transthoracic echocardiography in the localization and characterization of an intracardiac bullet fragment. Intracardiac localization is important to the surgeon contemplating juncture or follow-up operative intervention. Proximity to the conduction a whole a major coronary artery or vein, or intracardiac cavity may mitigate in favor of retrieval of the intracardiac bullet fragment, whereas intramyocardial localization may mitigate in favor of a more conservative surgical approach as was enlist in one's serviceed in this case. In patients who receive a gunshot hurt to the chest and are suspected of having cardiac involvement and who do not require immediate operative intervention to sustain life, TEE should be give employment toed to locate and characterize the bullet fragment as well as the stretch of myocardial damage if transthoracic echocardiography fails to do so

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