Successful repair of a penetrating right atrial gunshot injury via right posterolateral thoracotomy in a resource-limited hospital: a case report.

BACKGROUND: Penetrating cardiac injuries are uncommon but frequently fatal, particularly after gunshot wounds. Diagnosis may be challenging when pleural bleeding predominates, and pericardial fluid is minimal because blood may decompress through a pericardial defect into the thoracic cavity.

CASE PRESENTATION: A 25-year-old man sustained a penetrating chest gunshot wound during wartime and presented to a resource-limited hospital in hemorrhagic shock with a massive right hemothorax. Right tube thoracostomy immediately drained approximately 900 mL of blood, but he remained hemodynamically unstable. Computed tomography demonstrated a large retained right hemothorax with only a small pericardial effusion, raising suspicion of cardiac injury with decompression into the pleural space. Emergency right posterolateral thoracotomy was selected because the injury pattern was predominantly right-sided and sternotomy equipment was unavailable. Exploration revealed a 3-cm laceration of the anterior right atrial wall near the base of the right atrial appendage, together with injuries to the right middle and lower lobes. Atrial bleeding was controlled with digital pressure and repaired using a running 4-0 polypropylene suture. The pulmonary injuries were sutured, the pericardial space was evacuated and left open for pleural drainage, and a chest tube was placed. Recovery was uncomplicated, and the patient was discharged on postoperative day 6.

DISCUSSION: Minimal pericardial effusion does not exclude major cardiac injury when a pericardial breach permits decompression into the hemithorax. Persistent shock and a compatible wound trajectory should prompt urgent operative exploration.

CONCLUSION: Right posterolateral thoracotomy may provide effective exposure for definitive right atrial repair when sternotomy is not feasible.