Delayed Cardiac Injury from Gradual Bullet Fragment Erosion into the Right Ventricle

Penetrating cardiac injuries are among the most lethal of all traumatic injuries, with many studies citing mortalities of 70-90% [1- 3]. Such injuries account for a very small proportion of annual trauma admissions (0.1%) with most institutions reporting fewer than 10 cases per year [3]. This presents a challenge to trauma care providers in becoming adept at rapidly identifying and treating penetrating cardiac injuries. Moreover, in contrast to other injury mechanisms, survival from penetrating cardiac injuries has shown only modest improvement over the last several decades. Most importantly, a high index of clinical suspicion, rapid diagnosis, and expeditious surgical treatment yields the best chance of survival. Current understanding of this injury pattern is largely based on case series due to its rarity. This manuscript adds to the body of literature on penetrating cardiac injuries by detailing a 29-year-old male who experienced fullthickness right ventricular erosion from cardiac contraction against an abutting bullet fragment, a process that developed within three hours from the time of injury. We will describe the epidemiology and review the diagnosis and treatment of penetrating cardiac injuries with specific reference to our unusual case.