Myocardial ischemia caused by external compression due to shotgun bullets

Cardiac injuries resulting from shotgun bullets may be lifethreatening and are often fatal (1). People who sustain a bullet injury to the myocardium repeatedly do not have a chance to receive medical or surgical treatment. They usually die due to cardiac tamponade or hemorrhagic shock (2). Some fortunate cases with acute or chronic myocardial ischemia can be treated successfully (3). Here we present the case of a patient with metallic shotgun bullets in the myocardium. A 48-year-old healthy farmer was wounded with shotgun bullets in his chest during a fight. Thereafter, he had exercise and stress induced retrosternal chest pain. He was referred to cardiology department 3 weeks later due to increase in the severity of chest pain. Physical examination showed four bullet-entry holes on his chest. A 12-lead electrocardiography (ECG) showed T wave inversions in inferior leads. Cardiac markers were within normal ranges. Myocardial perfusion scintigraphy showed ischemia in the lateral and inferior segments. Coronary angiography revealed a critical stenosis in proximal third of the left circumflex coronary (Cx) artery, secondary to external compression of an adjacent metallic bullet. This bullet was moving together with the critical stenosis of the Cx artery and was constantly observed in the proximal segment when images were obtained from different angles. Therefore, it was thought that the stenosis was primarily compressed externally in the proximal Cx artery. The external compress could be revealed with intravascular ultrasound (IVUS). H