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Volume J IIkdki1! JOUlna! urlhe NumbcI3.o4 h!;tlnk I{epuhlif or Ir;ul I'ayiz &. Zemc�1an U6!! Fall &. Win1cr 191i9 ARTILLERY SHELL FRAGMENTS IN THE HEART: DIAGNOSIS AND MANAGEMENT Downloaded from mjiri.iums.ac.ir at 3:40 IRDT on Wednesday May 10th 2017 M.A. SADR-AMELI, M.D., M. MOHAJERI, M.D. ANDA. MOHEBI, M.D. From Ihe SJwhid Rajai Hearl Hospifal, lrall VI/iVCT.!"i/), of Medical ScieIlCCJ, Tehran, Islamic Republic of frail. ABSTRACT Delayed evaluation and management of penetrating cardiac injuries especially mortar fragments were performed in 30 war victims in the Shahid Rajai Heart Hospital, Tehran. All were men with a mean age of 20.7 years. Pleuritic chest pain was the most common symptom (53.3%), while physical examination was negative in the majority of cases (66.8%). 50 percent of the cases had pericardial effusion on the echocardiogram. The right ventricle was the most frequent site of involvement (26.6%) followed by the left ventricle (16.6%), right atrium, left atrium, aorta (each 13.3%), pulmonary trunk (10%), and inferior surface of the heart (6.6%). More than half of the cases had associated hemothorax. Shell fragments were removed in all cases but two. Fragments larger than one centimeter in the vicinity of the heart structures in the pericardium are recommended to be removed. MiIRl, Vol.3, No.3 & 4,109-112,1989 their second hospitalization was five days (range INTRODUCTION three-12 days). Pleuritic chest pain was the most Penetrating injuries of the heart (pericardium and common symptom, occurring in 16 cases (53.3%) problem confronting the surgeons and cardiologists complaint in the remaining 3 (10%). On physical infrequent incidence of cardiac involvement in thor cardiac findings. Pericardial friction rub was present cardiac structures) have always been an unusual followed by dyspnea in II cases (36.7%) and no involved with these cases. The literature show the examination. 20 cases (66.8%) showed no abnormal acic penetrating trauma during war with improving survival rates. I .:! in 8 (26.6%), mitral regurgitation (MR) in one Delayed evaluation and manage (3.3%), and continuous murmur in supraclavicular heart were not fully examined. We studied 30 war cases had a chest tube because of hemothorax, 11 in ment of patients with artillery shell fragments in the fossa in another case (3.3%). More than half of the victims after stabilization by catheterization and the left and five in the right side at the time of angiography. Most of them underwent operation. hospitalization. ECG was normal in 26 cases (86.6%) The clinical,. paraclinical, as well as surgical data are and the remaining four showed ST-T changes. [n reported. chest X-ray, no abnormality except increased car diothoracic ratio in six cases (20%) was detected. Shell fragments were seen every where within the MA TERIAL AND METHODS cardiac silhouette (the most common site was the anterior of the right ventricle). Thirty young men aged 17 to 34 years old (mean 20.7) were admitted to our hospital because of Echocardigram showed pericardial effusion in nearly half of the cases (50%) and one patient mortar shell fragments in the heart. The mean interval between the time of injury (in the fronts) and showed left ventricular volume overload (due to MR). Fluoroscopy in different views was performed 109 Downloaded from mjiri.iums.ac.ir at 3:40 IRDT on Wednesday May 10th 2017 M.A.Sadr Ameli, M.D., et al Fig. I. Lefl vt.:ntrit.:u[ar angiography in right anterior oblique view shows the fr<Jgmcnt in Ihe righl vcntride. in all patients to differentiate those with fragments in of the pericardium, cardiac wall, interventricular sep the pericardium from those with a superimposed tum, perforating or lacerating wounds of the cardiac shadow on the cardiac silhouette (extracardiac). valves, chordae tendineae, or papillary muscle; and Catheterization ancl angiography were done on all coronary vessels. During battle the wounding agents in patients. The site of shell fragments (all cases were most of the cases are shell fragments and Flechette inside the pericardium on or within cardiac struc 1.2 (the Flechette is a small dart like missile which has a tures) were anterior aspect of RV (eight cases), great penetrating ability due to its light weight, shape (two cases). right atrium (four cases), left atrium are lateral wall of LV (three cases), posterior part of LV with sharp angles, and great velocity). These wounds (four cases). anterior part of ascending aorta (three cases), left aspect of ascending aorta (one case), main pulmonary trunk (three cases). and inferior surface (fragment frequently associated with penetrating occur in patients with penetrating wounds of the chest, neck, and upper abdomen. The area of exposure of the of the heart (two cases). In three cases the findings of angiography most wounds of the pericardium, although they may also anterior chest wall of each cardiac chamber and the site) were different from intrapericardial great vessels differs markedly (55 per cent of the anterior surface is comprised of RV, 20 nuoroscopy. One patient showed two plus mitral regurgitation due to chordal laceration and a subcla percent LV, 10 percent RA, 10 percent great vessels, vian arterio-venous fistula was detected in another and5 percent vena cava:'i). In OUfcases there was similar patients and no abnormality was demonstrated. angiography and fluoroscopy data in three patients patient. Coronary angiography was done in all sites Fragments in all patients except two (which were of involvement.s The difference between could be due to displacement of the fragment or inaccuracy of the latter in comparison to angiography. less than I em) were removed by open thoracotomy with Projectile injuries carry a very serious outlook, and no complication. perhaps only 10 to 20 percent of these individuals will fall into a salvageable category. The experience in Vietnam demonstrated that only patients with relative DISCUSSION ly small wounds survive long enou8h to reach a hospit The chest wall offers little protection to the heart al, while those with more serious cardiac wounds which variety of cardiac lesions including penetrating wounds reach a medical center and when they do. are usually produce exsanguination and shock rarely survive to from projectile wounds. These wounds may produce a 110 Downloaded from mjiri.iums.ac.ir at 3:40 IRDT on Wednesday May 10th 2017 Artillery Shell Fragments In I-leart Fig. 2. Left ventricular angiugraphy in left anterior ohlique view sbows a large fragment in IhL: right atrium. not successfully trealed. I Lacerating or penetrating artery to cardiac chamber fistula; aorta to pulmonary wounds frequently result in immediate hemorrhage of artery communications; atrioventricular defects; lac varying magnitude. The severity of thc hemorrhage eration of valve leaflets or chordae tendineae; and and whether it is intra- or extrapericardial determine ventricular aneurysm. 7 The complica tions of infection. the clinical picture and dictate the requirement of pericarditis, embolization and dysrrhythmias may also therapy. Where there is intrapericardial hemorrhage occur. Recurrent post-traumatic pericarditis compli with a sealed pericardial wound. cardiac tamponade is cates about 20 percent of all cases of penetrating heart the major thrcat;6whercas when the pericardial wound wounds and is similar to post-pericardiotomy syn is open and bleeding occurs freely into the pleural drome. Symptomatic management is recommended space, loss of circulating blood volume is the major unless other sequelae such as purulent or constrictive danger. All of our patients were in a relatively stable pericarditis develop which need surgical intervention. situlalion at the time of adminance due to an ilvcragc Coronary artery injuries. depending upon the size of lag interval offive days from injury at the front. That is the injured vessel. call result in cardiac tamponade and why we call it "delayed evaluation." Thc treatment of varying clegress of myocardi<1! ischemia or myocardial and or continuous intrapericardial hemorrhage, is tion of a projectile within the heart. Embolization of these lesions, when they are manifested with massive infarction. Penetrating wounds may resuiL in the reten immediate surgical repair which appears to be the such a foreign body. or of the thrombus associated with treatment of choice for all penetrating cardiac wounds. it, has occurred. K The possibility of bacterial endocar Pericardiocentesis should be useel in patients with clitis is also present if the projectile is not completely cardiac tamponade only to provide time for a safe embedded in the myocardium. Several patients with operation. Pericardiocentesis as a mode of treatment is intracarcliac projectiles have developed cardiac neuro not accepted because in most cases thoracotomy sis with an almost maniacal desire for removal of the reaches a pericardium filled with large clots which foreign body. A penetrating wound of the great vessels bleeding is a common finding after initial pericardial possible subsequent rupture, or of an arteriovenous renders pericardiocentesis ineffective and continued may result in the formation of a false aneurysm. with aspiration. fistula, producing either immediate or latent signs and Residual or delayed sequelae of penetrating symplOms of congestive heart failureY These possible wounds of the heart include structural defects such as a complications suggest thot after precise angiographic ventricular or atrial septal defect; 'aorta or coronary localization, elective extraction may be the preferred 111 M.A.Sadr Ameli, M.D., et al management of such projectiles in the heart. Extensive REFERENCES military experiences suggest that any foreign body in the thorax larger than 1.5'''' in size should be removed due to possible late complications. Objects even smal lerthan this may be removed if they lie against the heart Downloaded from mjiri.iums.ac.ir at 3:40 IRDT on Wednesday May 10th 2017 and great vessels where they may cause major damage · by erosion The treatment of choice is open thoraco tomy which allows effective control of hemorrhage, relief of tamponade and removal of fragments where possible. '.J I. GicJchinsky I, Lieutenant C, Me Namara J: Cardiac wounds at a militnry evacuation hospital in Victl.l experience,J Thorac Cardia-Vase Surg 60: 603, 196!J. 2. Zakharia AT:Cardiovilscular and IhorOlcic injuries in the Lebanon war; Analysis at 300U personal c<lscs. J Thorae Cardiovasc Surg 89: 723-733. 1985. 3. Eslrcra A S, Schreiber J T: Management of acute cardiac trauma, Cardial Clin 2: 239, 19H4. 4. Webb W R: Thoracic trauma. Surg Clin N Amer, Philadelphia, W,B. Saunders, 54:l l7!}, 1974. In our cases all the fragments larger than one 5. Symbas P N: Trauma to the hean and great vessels. Grunc and centimeter were removed. In two cases because of multiple small fragments (less than 0.5""), operation Stratton. Inc .. New York. 1978. 6. IS<lncs J P: Sixty penetrating wounds of the heart. Surgery45: 696. 1959. was not carried out. 7. Symbas P N. Oi Orio 0 A. Tyras 0 M. et al: Penetrating cardiac wounds: significant residual and delayed sequelae. J TIlOme Cardiovasc Surg 66: 526. 1973. 8. Bland E F, Beebe G W: Missilcs in the hean: A 20 year follow-up report of world war cases. N EnglJ Med274: 1039,1966. 9. Symbas P N. Schlant R C, logan W D. ct al: Traumntjc ,l-onicopulmollnry fistula. Ann Surg 165: 614,1976. 112