Gunshot injuries to the heart are often seen in cardiac surgical practice. Victims are usually investigated with various types of imaging modalities, including simple chest X-ray (CXR) which is a primary imaging modality that can easily locate a bullet and is useful in monitoring before surgical intervention as bullets may migrate. A 32-year-old man was admitted as an emergency in a primary hospital after being injured by a gunshot to the chest. The bullet entry was over the back of the left shoulder with no exit point seen. The chest X-ray showed left pleural effusion and a retained intrathoracic bullet. A chest drain was inserted and drained 2200 ml of blood. Computed tomography (CT) scan showed an intracardiac bullet associated with left lower lobe contusion and left-sided hemothorax. He was urgently transferred to theater for exploration via left thoracotomy. The bullet could not be found so the inlet point in the left ventricle was sutured. After stabilizing the patient, he was referred to a specialized cardiac center for further management. The patient arrived at our center 2 days after the injury, fully conscious and hemodynamically stable. On arrival, chest X-rays were obtained to rule out possible migration of the bullet and revealed that the retained bullet was still within the cardiac silhouette. The X-ray appearance of the bullet showed a characteristically double contour, strongly suggesting that the bullet had lodged in the heart muscle and was moving with each heartbeat. The patient was transferred to the theater for median sternotomy. The aorta, superior vena cava, and inferior vena cava were cannulated, and cardiopulmonary bypass was initiated. The aorta was cross-clamped and the cardioplegia was given. Palpation of the still heart readily identified the bullet within the interventricular septum. The left ventricle was opened 1 cm from the left anterior descending artery just on top of the bullet. The bullet was successfully retrieved. The bullet was transfixing the septum causing a small ventricular septal defect which was closed using a Teflon patch and the ventricle was repaired. The double contour appearance of the bullet indicates that the bullet is moving and strongly suggests an intramyocardial position.

中文翻译：

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罕见的X线胸片诊断心内膜子弹：病例报告

在心脏外科手术中经常会看到枪伤心脏。通常采用各种类型的成像方式对受害者进行调查，包括简单的胸部X射线（CXR），这是一种主要的成像方式，可以轻松地定位子弹，并且由于子弹可能会迁移，因此在进行手术干预之前进行监测很有用。一名32岁的男子因胸部开枪受伤，被送往基层医院急诊。子弹入口位于左肩的背面上方，看不到出口点。胸部X线片显示左胸腔积液和保留的胸腔内子弹。插入胸腔引流管并排出2200 ml血液。计算机断层扫描（CT）扫描显示心内膜子弹与左下叶挫伤和左侧血胸有关。他被迫通过左胸廓切开术转移到战区进行探索。找不到子弹，所以缝合了左心室的入口点。在使患者稳定之后，他被转到专门的心脏中心进行进一步治疗。受伤后两天，患者来到我们中心，完全清醒并且血液动力学稳定。到达后，获得胸部X射线以排除子弹可能的迁移，并显示保留的子弹仍在心脏轮廓内。子弹的X射线外观显示出特征性的双重轮廓，强烈暗示子弹已经驻留在心肌中，并且随着每次心跳而移动。该患者被转移到剧院进行正中胸骨切开术。插管主动脉，上腔静脉和下腔静脉，并开始体外循环。主动脉被交叉钳住，并出现了心脏停搏。触诊静止心脏很容易就能确定室间隔内的子弹。左心室位于子弹顶部，距左前降支动脉1 cm。项目符号已成功检索。子弹穿过隔膜引起小室间隔缺损，用特氟隆膜片将其闭合并修复心室。子弹的双重轮廓外观指示子弹正在移动，并强烈暗示心肌内位置。左心室位于子弹顶部，距左前降支动脉1 cm。项目符号已成功检索。子弹穿过隔膜引起小室间隔缺损，用特氟隆膜片将其闭合并修复心室。子弹的双重轮廓外观指示子弹正在移动，并强烈暗示心肌内位置。左心室位于子弹顶部，距左前降支动脉1 cm。项目符号已成功检索。子弹穿过隔膜引起小室间隔缺损，用特氟隆膜片将其闭合并修复心室。子弹的双重轮廓外观指示子弹正在移动，并强烈暗示心肌内位置。