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

BACKGROUND: 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. METHODS: 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. RESULTS: 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%. CONCLUSIONS: 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.) LEVEL OF EVIDENCE: Therapeutic/care management, Level IV.