Conservative management of retained cardiac missiles: case report and literature review.

Intracardiac foreign bodies may be caused by direct penetrating trauma, embolization from injury to another area of the body, or iatrogenically from fragments of intravascular access devices. Penetrating cardiac trauma commonly presents with a hemodynamically unstable patient necessitating emergent life-saving procedures. Missile embolization to the heart can occur after injury to systemic and pulmonary veins. Central venous access devices may fracture after placement and embolize. Especially in the setting of penetrating cardiac trauma, these intracardiac foreign bodies require expeditious removal. Limited data exist regarding the conservative management of intracardiac material after trauma. We present the case of a 42-year-old male soldier injured in a mortar blast in Iraq who suffered multiple injuries to include a right hemopneumothorax and soft tissue injuries to the chest and both lower extremities that was found to have a 2-cm by 2-mm intracardiac metal fragment. Additional imaging revealed a metallic fragment localized to the interatrial septum. The patient suffered no adverse sequelae from nonoperative management. A review of the world literature regarding the subject of posttraumatic retained cardiac missiles (RCMs) is also included to help future surgeons in the management of this rare entity.

Effects of metal fragments on nerve healing in extremity injuries using a rat peroneal nerve model.

BACKGROUND: On the modern battlefield, the majority of injuries currently seen are to the extremities, often involving a large number of metallic fragments. Although they are typically left in place, the effects of these retained metal fragments on nerve healing have not been studied. STUDY DESIGN: In a rat model, the right peroneal nerve was surgically sectioned and reanastomosed (control group). In the study group, metal fragments from an artillery casing were placed around the reanastomosed peroneal nerve. Functional recovery in both groups was evaluated over a 4-week period by measuring maximum ankle dorsiflexion captured on video as the animals walked through a tunnel. Morphologic analyses included distal and proximal axon counts, measurement of nerve fiber and axon diameter ratios, and myelin thickness. RESULTS: A significant decrease (p < 0.05) in return toward baseline for the rats' ankle angle in the nerves exposed to metal fragments was noted at weeks 2 through 4. Distal axon counts were significantly less (p < 0.05) in the metal fragment group for weeks 1 through 4. Proximal axon counts were increased in both groups, with a greater (p < 0.05) increase in the metal fragment group. CONCLUSIONS: Functional recovery after rat peroneal nerve transection and repair is decreased when metal fragments are placed in and around the injury site. Select histologic indicators of nerve regeneration showed decreased healing when exposed to metal fragments. Further studies of functional recovery in patients sustaining penetrating injuries from bullets or explosive devices are indicated.

Evaluation of the effect of sildenafil and vascular endothelium growth factor combination treatment on skin flap survival in rats.

BACKGROUND: Distal ischemic necrosis of surgical flaps remains a challenging problem for the reconstructive surgeon. Recent studies have shown that either sildenafil or vascular endothelium growth factor (VEGF) treatment significantly improves ischemic skin flap viability. In this study, the effect of the combination of sildenafil and VEGF165 was evaluated on a rat skin flap model using orthogonal polarization spectral imaging and histologic analysis. METHODS: Rats were assigned to either a sham (n = 31), vehicle (n = 24), sildenafil (n = 24), VEGF (n = 23), or sildenafil and VEGF combination treatment (n = 21) groups. Distances from the distal end of the flap to avascular, stasis, and normal capillary blood flow zones were determined using orthogonal polarization spectral imaging on a skin flap model. Vessel density assessment was done at 7 days post surgery. RESULTS: Imaging analysis showed significant reduction in avascular and stasis areas in sildenafil and VEGF combination-treated groups at 7 days post surgery (p < 0.05). The combination-treated group, however, was not significantly different when compared to the group treated with sildenafil only. The sildenafil-treated group showed a significant (p < 0.05) reduction in both areas at day 7 compared to the VEGF and control groups. Histologic analysis showed no significant differences in vessel density between the groups. CONCLUSION: The combination of sildenafil and VEGF decreases the extent of avascular and stasis zones in skin flaps. The skin flap improvement seen with the combination treatment was similar to the sildenafil treatment alone suggesting that enhanced flap survival was due solely to the effect of sildenafil.