A patient, trying to commit suicide, shot himself by contact and was transferred to the emergency department with dyspnea and hypotension. Two foreign body entry points were discernible in the patient's left anterior thoracic wall, with minor bleeding. An immediate bedside transthoracic echocardiogram revealed an echolucent structure wedged at the apical myocardium and a large pericardial effusion (Figure 1A and Video). The chest X-ray that followed revealed a left-sided pneumohemothorax and two bullets, one at the site of the cardiac apex (Figure 1B1 and C1) and the second at the spinous process of the 12th thoracic vertebra (Figure 1B2 and C2). Emergent cardiothoracic surgery was deemed necessary to remove the bullet from the heart, fortunately with no complications. The patient recovered ten days after the event and received close psychiatry follow-up. Our patient was lucky to survive because penetrating cardiac traumas caused by gunshots usually result in devastating fatal injuries. However, in our case the embolization and wedging of the bullet directly in the myocardium of the left ventricle, without causing perforation, was a damage-limitating factor, giving time for surgical treatment.

Figure 1.

(A) Four-chamber view, transthoracic echocardiogram, showing the echolucent bullet at the apical myocardium with acoustic shadow (arrow). (B and C) Chest X-ray depicting a left-sided pneumohemothorax and two bullets, one at the site of the cardiac apex (B1 and C1) and the second at the spinous process of the 12th thoracic vertebra (B2 and C2).

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