Conservative management of a retained bullet in the right atrioventricular groove following a penetrating thoracic gunshot wound: a case report

Background: Penetrating cardiac injuries from firearms are highly lethal, with the majority of victims dying at the scene from exsanguination. A minority of patients who reach hospital alive harbor a retained intracardiac or pericardial projectile, posing a clinical dilemma: while extraction has historically been favored to prevent migration, embolization, infective endocarditis, conduction abnormalities, and lead toxicity, contemporary evidence supports selective conservative management in hemodynamically stable patients without active hemorrhage, structural cardiac injury, or arrhythmia. Bullets retained within the atrioventricular (AV) groove are particularly hazardous to extract because of adjacent coronary arteries and conduction tissue, and reports of conservatively managed AV-groove projectiles are rare. This case adds to the limited literature describing successful non-operative management of a retained AV-groove bullet.

Case Description: A 25-year-old previously healthy man sustained a single gunshot wound to the right chest and remained hemodynamically stable throughout inter-hospital transfer. Imaging suggested a projectile near the right atrium, but localization was limited by metal artifact. Transthoracic echocardiography demonstrated mild apical pericardial effusion with preserved biventricular function and no valvular injury. Right video-assisted thoracoscopic surgery (VATS) with pleuro-pericardial window drained 100 mL of serosanguineous fluid but did not identify the projectile. Conversion to median sternotomy revealed a bullet within the right AV groove without active hemorrhage. Intraoperative transesophageal echocardiography demonstrated normal biventricular function with no regional wall motion abnormality and no tricuspid regurgitation. Following multidisciplinary discussion, the family elected to forgo extraction. The pericardium was closed and chest drains placed. Postoperative echocardiography, electrocardiography, and serial serum lead levels remained within normal limits. The patient was discharged on postoperative day 7 and remained well at 6-month follow-up.

Conclusions: Conservative management of a retained bullet within the AV groove is a reasonable option in hemodynamically stable patients with intact cardiac function, no active bleeding, and no evidence of mechanical or electrical compromise. Avoidance of extraction in this anatomically sensitive region minimizes procedural risk to the right coronary artery and conduction tissue, but mandates structured long-term surveillance for migration, infection, conduction abnormalities, and lead toxicity.