A retrospective observational study on management of penetrating gunshot and migrating projectile injuries to the heart during the war in Ukraine.

Abstract

Penetrating cardiac injuries caused by firearms are associated with extremely high prehospital and early in-hospital mortality. During wartime, civilian cardiac surgery centers are increasingly involved in the management of complex gunshot and fragment-related cardiac injuries, yet published evidence from nonmilitary practice remains limited. We conducted a retrospective observational study of civilian and military patients with penetrating cardiac gunshot or fragment injuries treated surgically at a tertiary civilian cardiac surgery center between February 2022 and December 2025. Patients with severe cardiogenic shock or rapidly progressing tamponade were typically managed at frontline hospitals; referred patients who survived initial resuscitation underwent definitive cardiac surgery at our institution. Demographic, clinical, imaging, operative, and outcome data were analyzed descriptively. Among 69 patients undergoing cardiac surgery for combat-related injuries, 25 required surgical removal of intracardiac foreign bodies. Median age was 38 years [interquartile range (IQR): 32-47], and 92% were males; 72% were military personnel. Metallic fragments accounted for 92% of foreign bodies, most commonly located in the ventricles. All procedures were performed in a hybrid operating room; cardiopulmonary bypass was used in 32% of cases, while 68% were managed off-pump with bypass standby. Neodymium magnet-assisted extraction was used in 80% of procedures. Median operative time was 117 minutes (IQR: 89-133). Median intensive care unit stay was 3 days (IQR: 2-5), and hospital stay was 13 days (IQR: 8-17). In-hospital and 30-day mortality were both 4%. Surgical management of penetrating cardiac gunshot and fragment injuries can be safely performed in civilian cardiac surgery centers during wartime. A multimodal imaging strategy, individualized use of cardiopulmonary bypass, hybrid operating room infrastructure, and adjunctive magnet-assisted techniques facilitate effective treatment with favorable early outcomes. (J Trauma Acute Care Surg. 2026;00: 00-00. Copyright © 2026 Wolters Kluwer Health, Inc. All rights reserved.). Therapeutic/care management, Level IV.