Right ventricular shotgun pellet embolism: Case report and r
A 41-year-old woman presented to the emergency room after sustaining 2 shotguns wounds in the abdomen and left thigh from a short distance. Upon admission, the patient was hemodynamically stable with normal blood pressure and respiratory rate. Physical examination showed multiple ballistic wounds in the abdomen, both thighs, and groins, associated with a deep wound on the upper-outer side of the left thigh. No exit wound was identified. Palpation found an upper abdominal guarding. Peripheral pulses were normally palpated in the 4 extremities.

No abnormality was detected on the focused assessment with sonography for trauma. A whole-body CT scan using spiral acquisition with intravenous contrast administration and iterative algorithm for metal artifact reduction reconstruction was performed. It showed multiple small pellets within thighs, groins, abdominal wall, and inside the abdomen and pelvis. Mild pneumoperitoneum was present without any evidently associated organ or vascular injuries. At the supra-diaphragmatic level, an isolated metallic foreign body was seen at the lower part of the right ventricular wall. Its exact location was unknown due to metallic artifacts and cardiac motion, the patient was a tachycardiac with a heart rate of 115 during the acquisition. The metallic object seen on CT scan and TTE could be a penetrating pellet which directly reached the mediastinum. Another possibility is a migrating pellet through the venous system to the right heart cavities even though there were no evident associated vascular injuries seen on the whole-body CT scan.

ECG-gated Cardiac CT scan was performed 5 days after admission using retrospective gating and iterative algorithm for metal artifact reduction reconstruction after administrating 10 mg of intravenous Tenormin (Atenolol) reducing the heart rate from 100 to 75. It confirmed the presence of a right ventricular intracavitary metallic pellet measuring 3 mm entrapped within the trabeculations throughout the cardiac cycle. There was no evidence of a penetrating thoracic injury or pericardial abnormality. The most likely diagnosis was therefore a metallic pellet embolism to the right ventricle migrated from the femoral veins. TTE was repeated 3 days later during the hospitalization showing the pellet within the same location in the right ventricle. It was decided after a multidisciplinary team meeting to follow conservative management and to start prophylactic anticoagulation for 1 month. It was controlled by serial TTE rather than CT scan to avoid radiation exposure, looking for signs of stability, migration, or myo-pericardial complications. On the first 2 monthly follow-ups, it was stable and no further investigations or workups were done.