Figure 1: Pinpoint skin wound at the right side of midline along the intermammary line (arrow)
Figure 2: Axial view of chest computed tomography showing a nail passing through the sternum and pericardium with pericardial effusion
Figure 3: Bedside transthoracic echocardiographic view showing pericardial effusion (arrow) with right ventricular collapse during diastole. RV: right ventricle, RA: right atrium, LV: left ventricle, LA: left atrium
Figure 4: Postoperative image of the extracted nail of 4-cm in length
Figure 5: Intraoperative view of the direct repair of right ventricular injury (arrow) through left anterior thoracotomy



Age (y)


Cause of injury

Physical examination

Site of injury

Surgical approach

Surgical technique

Georghiou et al [9]


14 y


Blast injury

An entry wound at the level of the 8th IC space

Right ventricular muscular.

Median sternotomy with CPB

Removal of the nail and repair of injury with a pledgeted suture

Nolke et al [10]


Case 1: 16 y
Case 2: 36 y

Cases 1 and 2: M

Case 1 and 2: Accidental shot

Cases 1 and 2: Puncture (entry point ) wound under the left nipple

Case 1: Left ventricular apex
Case 2: Right ventricle

Cases 1 and 2: Left anterior thoracotomy

Cases 1 and 2: Repair of the defect with pledgeted sutures

Straus et al [11]


62 y


Suicidal shot by a pneumatic nail gun

An entry at left anterior chest. Hemodynamic stable

Two nails: One within the left ventricle, and another one in anterior mitral valve leaflet.

Median sternotomy with CPB

Extraction of nails. Repair of mitral valve leaflet was not required

Guo and Myers [12]


25 y


Accidental shot

A nail protruding at the sixth left IC space

Anterior wall of the right ventricle

Median sternotomy

Extraction of the nail after tying a purse-string suture around it

Tuladhar et al [13]


49 y


Suicidal shot

Two pinpoint blood clots near the xiphisternum

One nail in the rectus insertion. Another one enters right ventricular free margin and exits through the inferior surface of the left ventricle

Median sternotomy with CPB

Removal of both nails. Wounds were repaired and buttressed

Comoglio et al [14]


75 y


Accidental shot (unnoticed initially)

A small wound on the left chest wall

Left ventricular wall

Median sternotomy

Gentle removal of the nail. Wounds were repaired

Jodati et al [8]


24 y


Accidental shot

Non-bleeding pinpoint skin wound

Anterior mitral leaflet

Median sternotomy with CPB

Removal of the nail. Repair of the anterior mitral leaflet

Madani et al [15]


17 y


Accidental shot

A punctiform entrance wound at the 2nd left IC space

The trunk of the pulmonary artery without transfixing its posterior wall

Median sternotomy

Extraction of the nail after tying a purse-string suture around it

Michalsen et al [16]


Case 1: 3 y
Case 2: 37 y

Cases 1 and 2: M

Case 1: Accidental shot
Case 2: Suicidal shot

Cases 1 and 2: Left parasternal puncture wounds

Cases 1 and 2: Right ventricle and interventricular septum

Case 1: Median sternotomy with CPB
Case 2: Median sternotomy with intravenous adenosine to slow the heart rate

Case 1: Nail extraction through small right ventriculotomy
Case 1: Nail extraction and repair of 2 holes in right ventricle

Kulaylat et al


29 y


Suicidal shot

Bloodless puncture wound at right 4th IC space

Right ventricle

Median sternotomy

Nail extraction and primary repair of torn myocardium

Ho et al [17]


51 y


Suicidal shot

One puncture wound at the right sternal border in the 4th IC space

Anterior right ventricular wall and diaphragm

Median sternotomy with CPB

Removal of the nail and closure of the two heart wounds and diaphragm.

M: Male. F: Female. IC: Intercostal. CPB: Cardiopulmonary bypass
Table 1: Characteristics and management of patients with stable hemodynamic status or delayed presentation after cardiac nail gun injuries