​Bullet to the Heart: A Case Report

Penetrating cardiac injuries (PCI) from gunshot wounds are among the most fatal forms of trauma, with prehospital mortality rates exceeding 90%. While the right ventricle is most commonly affected due to its anterior location, retained intracardiac projectiles are rarely encountered and pose significant management challenges. Cardiac tamponade, though potentially fatal, can sometimes provide a protective mechanism by limiting hemorrhage. The decision to surgically remove retained bullets remains controversial, particularly in hemodynamically stable patients. We report the case of a 51-year-old male who sustained multiple gunshot wounds, including a thoracic injury with an 8 mm bullet fragment retained in the right ventricle. On arrival, the patient was hemodynamically stable despite imaging revealing a pericardial effusion and a sternal fracture. A median sternotomy with pericardiotomy was performed, revealing a right ventricular epicardial wound without active bleeding. Due to the absence of cardiopulmonary bypass, the intracardiac bullet was not removed. The patient received prophylactic heparin and was monitored with imaging and serial exams. He was discharged without complications. This case highlights a rare presentation of PCI without overt tamponade physiology, despite the presence of a pericardial effusion. The patient remained stable throughout hospitalization, supporting the hypothesis that tamponade can temporarily contain hemorrhage. Conservative management of retained intracardiac projectiles may be appropriate in select patients, particularly when the projectile is embedded in the trabeculated myocardium and the risk of embolization is low. Literature suggests that long-term outcomes can be favorable with nonoperative management in stable cases. This case reinforces the importance of rapid surgical intervention for PCI, even in stable patients, and supports individualized, conservative management of retained cardiac projectiles in the absence of cardiopulmonary bypass. Further research is needed to define standardized protocols for managing intracardiac foreign bodies in trauma.