Management of Bullet Emboli to the Heart and Great Vessels

Firearm-related injuries account for 20% of all injury-related deaths and are responsible for 105,000 injuries annually. The occurrence of bullet emboli to the heart is exceedingly rare. Given the rarity of emboli, controversy exists over management. The primary endpoint of this study is to establish a management algorithm for venous bullet emboli to the heart.

A literature search was performed using PubMed and Google Scholar with the following search terms: cardiac bullet embolus, cardiac missile embolus, and bullet embolus. Any discoverable case report(s) or series after 1960 were included in the review. The following data points were collected: age, sex, presentation, imaging, foreign body entry site, foreign body destination site, management, and outcomes.

Fifty-four articles met our search criteria. A total of 62 patients with thoracic venous bullet emboli were identified with the following distributions: right atrium (9.7%), right ventricle (54.8%), pulmonary arterial tree (32.3%), and intra-thoracic inferior vena cava (3.2%). Only 11.3% of patients had symptoms directly related to the cardiac venous emboli; however, all patients with acute symptoms underwent immediate intervention. Of those patients with bullet emboli to the pulmonary arterial tree, 45% were observed; whereas, only 20% with emboli to the right heart were observed. Those without signs or symptoms usually underwent an intervention (72.7%). Endovascular retrieval was successful in 53% of attempts. Of the endovascular attempts that failed, 28.6% were observed and 71.4% underwent open retrieval. Those who were asymptomatic and observed had no reported adverse sequelae during the follow-up. No mortalities were discovered in this review.

Bullet emboli can prove to be a clinical challenge. Adjuncts such as X-ray, computed tomography, transthoracic, and/or transesophageal echocardiography help establish the emboli location. While observation in the asymptomatic patient is reasonable in some circumstances, most patients undergo removal. Removal of bullet cardiac emboli is safe with the availability of modern techniques.