Guardian angel on call
======================

* Mario Royo-Villanova
* Ruben Taboada Martín
* Silvia Sánchez Cámara
* Luis Falcón Araña
* Gustavo Herrera Cateriano
* Ana Ruiz Rodriguez

*   AORTA, GREAT VESSELS AND TRAUMA
*   CARDIAC SURGERY

A 49-year-old man was transferred from his local hospital to our centre with the diagnosis of cardiac tamponade as a result of a penetrating thoracic injury secondary to a self-inflicted air gun shot. A chest CT done earlier was given to us (figure 1).

![Figure 1](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/6/1/38/F1.medium.gif)

[Figure 1](http://heartasia.bmj.com/content/6/1/38/F1)

Figure 1 
Chest CT: (1) pellet, (2) central venous catheter, (3) pericardial drainage, (4) pericardial effusion and (5) thoracic wound.

On history, he only reported a paranoid personality disorder with adaptive symptoms.

Upon arrival he was slightly hypotensive, with 80/40 mm Hg, tachycardic, with 120 beats per minute and with an anterior pericardial catheter (placed previously at his hospital) that had collected 350 mL of bloody drainage.

After initial evaluation and under mild sedation, we performed a trans-oesophageal echocardiography (figure 2; online supplementary video 1) which showed a haematoma adjacent to the right ventricle and a tear of the anterior wall of the aorta with a foreign body lodged on the posterior aortic wall.

![Figure 2](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/6/1/38/F2.medium.gif)

[Figure 2](http://heartasia.bmj.com/content/6/1/38/F2)

Figure 2 
TEE long axis view: (1) anterior aortic tear and (2) foreign body.

The patient was then transferred to the operating room where after midline sternotomy and undergoing extracorporeal circulation, he was intervened. The findings included an enlarged haematoma in front of the aorta and right ventricle and a rupture of the anterior aortic wall (figure 3). That was later sutured. Through this rupture the pellet was removed from the posterior aortic wall, which seemed undamaged. After surgery he was readmitted to the ICU in a stable condition.

![Figure 3](http://heartasia.bmj.com/https://heartasia.bmj.com/content/heartasia/6/1/38/F3.medium.gif)

[Figure 3](http://heartasia.bmj.com/content/6/1/38/F3)

Figure 3 
Surgical view with the pellet on the rear aortic wall.

He was discharged asymptomatic from the ICU 2 days after surgery.

## Footnotes

*   Contributors All the contributors fulfil the three criteria for authorship requirements.

*   Competing interests None.

*   Patient consent Obtained.

*   Provenance and peer review Not commissioned; externally peer reviewed.