Missile Fragment Embolism of the Coronary Artery in a Patient with Coronary Artery Disease

A 51-year-old war veteran referred to us with typical chest pain and dyspnea on exertion. He had a history of hypertension from several years before, for which he had been prescribed anti-hypertensive medications. He also gave a history of missile fragment injury to his chest from the Iran-Iraq war, for which he had been hospitalized, but had received conservative medical treatment only. After admission and initial workup, echocardiography revealed mild left ventricular dysfunction with an ejection fraction of 45% and a metallic fragment at the diaphragmatic surface of the right ventricle. Coronary angiography showed significant stenosis at the LAD – Diagonal bifurcation, as well as a metallic fragment occluding the PDA branch of the right coronary artery. Coronary artery bypass surgery was performed successfully and the patient was discharged uneventfully. To the best of our knowledge, this is the first report of an embolized missile fragment to the coronary artery found incidentally in a patient undergoing surgery for coronary artery disease.