Bullet in the Right Ventricular Wall: Integrated CT, TTE, and Intraoperative 3D TEE in Safe Surgical Extraction

Abstract

Background: Penetrating cardiac injuries caused by bullets are rare, but potentially fatal that requires accurate diagnosis and precise management. An intracardiac bullet poses a significant problem due to high mortality rates and a wide range of immediate and long-term complications. The right ventricle is the most commonly affected cardiac chamber due to its anterior anatomical position. Multimodal imaging such as computed tomography (CT), transthoracic echocardiography (TTE), and transesophageal echocardiography (TEE) play a vital role in the diagnosis and surgical management of such cases.

Case Presentation: A male air rifle technician came to the emergency room with a penetrating right chest injury without loss of consciousness or significant respiratory symptoms. Preoperative computed tomography identified a tubular, metallic-density foreign body near the right ventricle; blooming artifact limited precise chamber identification. Transthoracic echocardiography revealed a hyperechoic mass at the right ventricular septal wall with normal cardiac structure and function. During surgery, manual exploration failed to locate the bullet, but intraoperative three-dimensional TEE precisely visualized and guided safe removal of the bullet embedded in the posterior RV wall. The patient remained hemodynamically and respiratory stable in postoperative care.

Conclusion: This case highlights the critical role of integrated multimodal imaging involving CT, TTE, and intraoperative TEE in accurately diagnosing and managing retained intracardiac bullets. Such integration optimizes surgical planning, minimizes intraoperative uncertainty, and improves patient safety and outcomes in complex cardiac trauma.