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An Arrow Through the Heart
Key words: cardiopulmonary bypass, left anterior descending coronary artery
A 54-year-old man suffered a self-inflicted penetrating chest wound from an automated crossbow used for hunting large animals (Figure 1), with an entrance wound in the left third intercostal space and an exit wound at the tenth intercostal space (Figure 2). The arrow was in the plane of the diaphragm and penetrated the left ventricle (LV), although no hemopericardium, hemothorax, or pneumothorax were identified. Intraoperative transesophageal echocardiography showed no significant mitral regurgitation despite the proximity of the arrow to the base of a papillary muscle (Figure 2; Videos 1 and 2).
We initiated cardiopulmonary bypass via the femoral artery and vein prior to median sternotomy. The anterior part of the arrow between the pericardium and the anterior LV wall was separated (Figure 3B). Next, we separated the posterior part of the arrow between the posterior LV wall and pericardium (Figure 3C). We confirmed that the arrow was between the left anterior descending artery and the diagonal branch in the anterior LV as well as between the posterior descending artery (Figure 3H) and posterior lateral branch (Figure 3F). Following extraction, the defects were closed with felt-reinforced horizontal mattress stitches and over-and-over stitches as in the linear LV closure. Of note, there were fibrin clots surrounding the arrow (Figure 3E). We discontinued cardiopulmonary bypass smoothly and achieved excellent hemostasis without segmental abnormalities in LV motion and valve malfunction. The patient was extubated several hours after the operation and had an uneventful postoperative recovery. Postoperative follow-up revealed that he was incredibly grateful to be alive and thankful to the multidisciplinary team that saved his life.
Affiliations and Disclosures
From the 1Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada; and 2Royal College of Surgeons in Ireland, Dublin, Ireland.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted January 15, 2022.
Address for correspondence: Subodh Verma, MD, Professor and Cardiac Surgeon, St. Michael’s Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada. Email: subodh.verma@unityhealth.to
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