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A 74 year old man was admitted because of suspected liver cirrhosis with refractory ascites and impaired renal function. As a soldier in the second world war he was injured by an explosive bullet from a Russian sniper in 1942 near Leningrad. Since this event, a systolic murmur has been known. One year ago he started to complain about fatigue, weight gain, and an enlarged abdomen. On chest xray the right heart and the pulmonary arteries were enlarged with augmented pulmonary vascularisation. A large number of metal foreign bodies were seen. Transthoracic echocardiography showed enlargement of the right ventricle and right atrium, paradoxical septal movement, and severe tricuspid regurgitation with pulmonary hypertension. Colour Doppler revealed a turbulent high velocity jet between the left ventricle (LV) and the right atrium (RA) (below). This shunt was confirmed by cardiac ventriculography in left anterior oblique projection (top right) showing a rapid flow of contrast medium from the left ventricle to the right atrium (large arrow). Many metal fragments also were detected. One large fragment, which presumably caused the penetration, was found embedded in the left posterior myocardial wall (small arrow). The left-to-right shunt amounted to 33% of pulmonary blood flow as determined by oximetry. In addition, coronary angiography showed a traumatic fistula between the enlarged right coronary artery and the right ventricle (bottom right, arrow). The patient underwent cardiac surgery successfully, with closure of a defect near the tricuspid annulus measuring 1 cm in diameter and closure of the coronary fistula.
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