Shot through the heart: who’s to blame?

A 67-year-old male with a remote history of gunshot wound (GSW) to the chest with cardiac injury and repair presented to the hospital due to progressive dyspnoea and orthopnea. Patient was recently admitted to an outside hospital and was found to have new heart failure and a left ventricular (LV) apical thrombus for which he was discharged on anticoagulation. During the current admission, our patient underwent a transthoracic echocardiogram which showed a mildly reduced ejection fraction (45%) and possible pseudoaneurysm at the mid-anterior/anteroseptal wall (Panel A, Supplementary data online, Video S1) as well as a mobile thrombus at the LV apex (Panel B). Given new reduced ejection fraction and wall motion abnormalities, a cardiac CT was obtained which showed normal coronaries with a non-communicating mid-septal ventricular defect (VSD) and evidence of a ventricular patch repair to the anterolateral LV wall and anterior RV (Panel C, D, Supplementary data online, Video S2). Cardiac MRI, similarly, demonstrated a non-communicating VSD and ventricular patch repair (Panel E, Supplementary data online, Video S3) with corresponding transmural late gadolinium enhancement (LGE) (Panel F). These serial findings were thought to be related to the prior GSW with bullet path from the anterolateral wall to anteroseptum and likely through the anterior RV.