Lucky in his misfortune: An arrow through the heart

Abstract

Crossbow arrows were weapons used in the Middle Ages. Nowadays, they are essentially used for sport practice. Those weapons can induce major lesions either by accident or by suicide attempt. We report the case of a 48-year-old man who attempted to commit suicide with a crossbow. As he reached the hospital hemodynamically stable, with no tamponade on echocardiography, we performed a contrast-enhanced computed tomography scan. The arrow crossed the left internal thoracic artery, the pulmonary artery root, the left atrium, and ended in right transverse process. We performed a salvage cardiac surgery. The patient recovered uneventfully. We present and comment on our management of the patient.

Learning objective

Penetrating vascular and cardiac injuries can be faced by many physicians. Fortunately, these situations are scarce. There are main principles to manage these lesions, but every clinical case has its own particularities. We wish to help practicians who might face similar cases.

Introduction

Penetrating vascular injuries can be faced by every surgeon. However, these situations are fortunately scarce. There are main principles to manage these lesions, but every clinical case has its particularities. We report the management of one impressive case of vascular injury: a crossbow arrow through the heart. We wish to help practicians who might face similar cases.

Case report

A 48-year-old man attempted to commit suicide with a crossbow arrow (Fig. 1a and b). The patient was described by the emergency team as hemodynamically stable. He was transferred at 9:30 PM to our referring cardiac surgical center and we decided to evaluate him directly in our operating room. The patient was Glasgow Coma Scale 14 without neurological defect (due to the necessity of sedation for agitation), pain was controlled with intravenous opioid analgesia. As he was hemodynamically stable, with no significant tamponade on echocardiography, we performed a contrast-enhanced computed tomography (CT) scan (Fig. 2). The arrow crossed the anterior chest wall near the left internal thoracic artery, the pulmonary artery root, the left atrium, and ended in right transverse process, that is why the neurosurgical team was contacted, and they advised us to remove the arrow.

Fig. 1.

Image of the arrow. (a) Before surgery. (b) After withdrawal from the chest.

Fig. 2.

Computed tomography scan images and reconstruction. (a) Axial. (b) Sagittal. (c) Frontal reconstruction. (d) Axial reconstruction.

At 11 PM, the anesthetic team set invasive pressure monitoring and central venous catheter, and we began a salvage surgery at 11:20 PM. First, we instituted femoro-femoral cardiopulmonary bypass with open Seldinger technique guided by transesophageal echocardiography (TEE). We chose to set extracorporeal circulation and then proceed to sternotomy to maximize the safety. There was a moderate and non-compressive hemopericardium. Once the pericardium was opened, we added a superior vena cava canula.

There were the following anatomical lesions from front to back: the arrow crossed the anterior chest wall near the left internal thoracic artery, transfixed the pulmonary artery root near the sino-tubular junction, transfixed the left atrium (from roof to posterior), and ended within a right thoracic transverse process.

Once at full-flow cardiopulmonary bypass and after snaring both venae cavae, we withdrew the arrow which presented a smooth, cone-shape tip (Fig. 3). We initially chose not to cross-clamp the aorta enabling to optimize the evaluation of lesions with potential blood loss. Air embolism was prevented with full-flow extracorporeal circulation and demonstration of no aortic valve opening at TEE, and major hemorrhage could be controlled with two field aspirators.

Fig. 3.

Withdrawal of the arrow after sternotomy and ignition of the extracorporeal circulation.

Then, we cross-clamped the aorta. We repaired the left atrium: the roof tear was fixed with two pledgetted overlock sutures and the posterior tear was also fixed with two overlock pledgetted sutures; the latter was accessed from inside the atrium through a Sondergaard's groove approach.

Then we focused on the pulmonary root lesion. We opened longitudinally the pulmonary artery. We saw a leaflet disinsertion and performed a leaflet reconstruction with El Khoury's plasty for the pulmonary valve. The good result of the plasty was assessed with hydrostatic test. We closed the pulmonary root with two overlock sutures.

Then, the aortic clamp was removed and cardiopulmonary bypass was weaned.

Hemostatic stiches with pledgets were needed to control a veinous hemorrhage which appeared after the withdrawal of the arrow near the transverse process. We also fixed a collateral of left internal thoracic mammary artery.

Valve function was assessed by TEE. Cross-clamp time was 67 min and cardiopulmonary bypass time was 108 min.

We also washed the pericardial and pleural cavities with hot ringer lactate before closing the sternum.

The patient recovered uneventfully and was discharged from intensive care unit at day 2 and from hospital at day 6 after satisfying transthoracic echocardiography. We also performed a control CT-scan to detect any remaining vascular lesion or bone lesion. A psychiatric follow-up was initiated.

Discussion

After fast clinic and echocardiographic evaluation, a discussion between surgical and anesthetic teams led to the decision to perform a chest CT-scan. The purpose was to determine the structures crossed by the arrow. Additionally, at that moment we did not know the length of the arrow and if there existed a risk for medullar spine. The patient had no lower limb paresis however the performance of our neurological examination was diminished due to the necessity of sedation. In our case, the arrow ended fortunately in a transverse process. To perform this imaging examination took about 40 min. If the patient had been unstable or with uncontrolled bleeding, we would go for salvage surgery by sternotomy. We did not request pre-operatively or in intensive care unit bronchoscopy or endoscopy of the esophagus to eliminate airways or digestive lesions. Indeed, we judged our CT-scan and its interpretation and per-operative constatations sufficient.

We first decided to set femoro-femoral cardiopulmonary bypass. Another option would have been to begin with sternotomy and canulate aorta and right atrium. Again, since the patient was very stable without active bleeding, we chose the safest strategy.

Besides, we did a median sternotomy also because of the structures involved. Another emergency cardiac approach is left anterior thoracotomy in the fifth intercostal space. In our case this fast route to the heart would have not been adequate to repair left atrium. We could have performed a clamshell procedure but according to us in the present case, it would have been more invasive without facilitating the surgery.

This is not the first case of accidental injury or suicide attempt with crossbow arrow [1], [2], [3], [4], [5], [6]. Futamura et al. [1] report a similar case but with the arrow transfixing ascending aorta and right bronchus. They present an interesting way to fix vascular injuries thanks to purse strings and without cardiopulmonary bypass. Gordeev et al. [2] treated a man who attempted suicide with two crossbow arrows with cardiac autotransplantation and hypothermic circulatory arrest. Another astonishing case is presented by Nakamura et al. [7]: a suicide attempt with a crossbow but this time the patient removed the arrow himself. They diagnosed a growing pseudoaneurysm of the arch and the patient benefited from thoracic endovascular aneurysm repair (TEVAR).

Crossbows were weapons in older times (Middle Ages), nowadays they are essentially used for sport practice. We might ask if it is wise that these crossbows can be bought without any license knowing the potential dramatic lesions induced by these weapons. There are two types of arrows [8]: conical or multiple-bladed broadheads. In our case the arrow was fortunately conical which enabled us to remove it without tearing the transfixed tissues.

The literature and our case emphasize patients with hemodynamic stability even with injuries in high pressure cavities or vessels. A transfixing weapon may itself induce hemostasis depending on its shape, morphology and the injured cardiac structures as well. Our case supports the general principle of removing the transfixing object only after surgical control of the concerned anatomical structures.

Above all, never remove the arrow outside from hospital. If time is available (hemodynamic and respiratory stability) make sure of every important lesion pre-operatively.

Patient permission/consent statement

Patient provided consent with research purpose.

Declaration of competing interest

The authors declare that there is no conflict of interest.