 The clinical and technical significance of foreign bodies located in the pericardium is very different from that of a missile in a chamber of the heart. However, pericardial and cardiac foreign bodies are inevitably linked by anatomical proximity in that they share technical features of exposure and cardiac manipulation and the difficulty in absolute differentiation without operation or autopsy. Certain pericardial missiles are removed to prevent suffuration, erosion, pain, and neurosis, whereas certain cardiac foreign bodies are removed to prevent embolus of the foreign body or associated thrombus, to reduce the danger of bacterial endocarditis, to prevent recurrent pericardial effusions, and to diminish myocardial damage. Parentetically, it should be added that pain and cardiac neurosis may assume importance in some cases. While originally hypothetical, experimental, or borrowed from the medical literature, these indications for removal have now had clinical support. Whether a retained foreign body be pericardial or cardiac, size and clinical manifestations will inevitably influence the decision for or against removal. It is emphasized that in this clinic it was elected not to remove more than one-half of the foreign bodies that were presumably located in the heart. Those not removed were all small and asymptomatic. The difficulty of certainty as to the intra-cardiac position of missiles is emphasized in that more than one-half of the so-called foreign bodies in the heart that were referred to this clinic for removal were found to be extra cardiac by careful fluoroscopic study. And though diagnostic proficiency improved with experience, approximately one-third of the missiles thought to be in the heart were found to be outside at operation. Once the decision is made to remove a missile from the pericardium or heart, the salient features of cardiac exposure are specific, adequate, direct approach rather than a standard heart exposure. Specific direct approaches are made to the indicated areas of the heart. Through the right anterior approaches, the superior venercava and the right oracle may be exposed. Through the left anterior region, access may be gained to the anterior aspect of the right ventricle and left border of the left ventricle. Posterolateral incision gives access on the right to the right oracle, inferior venercava, and right side of the posterior aspect of the left oracle. From the left posterolateral approach, the left side of the left or left ventricle can be exposed. The second salient feature of cardiac exposure is the conservation of the thoracic cage skeleton. Nothing is resected, nothing is discarded. The patient is left with a normal cage after operation. Third, the minimal dislocation of the heart from its position of optimum function. And finally, the maintenance of the moist epicardium to prevent excessive cardiac irritability. This rentgenogram is of a man referred to the center because he was thought to have a bullet in his heart. The lateral films and fluoroscopic examination strongly suggest that it is pericardial in position. And a tracheal anesthesia is used. The tracheal tube is placed after induction with intravenous pentathor. A simple direct anterior incision in the right fifth intercostal space will be used. Ribs are counted to select the proper intercostal space. Memory vessels are clamped, cut, and ligated. Intercostal nerves are injected with noblecane in oil. Intercostal muscles are divided and the pleura is opened. The bullet is carefully exposed. It is removed. The nitrous is cleansed and the culture is taken. A plug of fibrin foam impregnated with penicillin is placed in the nitrous. Cartilage is sutured. Pericostal sutures of catgut are used. The pleura is not closed in anterior approaches. No effort is made to expose the heart or pericardium without opening the pleura. In general, extra pleural exposures are less adequate, as well as time consuming and unnecessary. The muscles and fascia are closed in layers. Air is aspirated through a catheter as the lung is expanded by the anesthetist. Penicillin is injected into the pleural space. Five days later, the patient sutures are out and he feels quite well. If the missile in the previous case had been within the right oracle, with pericardio-auricular adhesions, or if the auricular wall had been thick enough to support sutures, this technique would have been used. Chest wall is opened in this same way. The fused pericardium is incised. Two rows of hemostatic guide sutures are placed. The outer row includes pericardium and oracle. The second row only oracle. These are crossed for hemostasis between intra-auricular maneuvers. However, pericardio-auricular adhesions do not always give solid suture support. Then an extra cardiac avenue to the chambers of the heart may have to be used. One missile in the right oracle was removed through this extra cardiac approach. The routine skin incision was made. Then the intercostal approach was carried between the third and fourth ribs, with division of the mammary vessels and section of the cartilages. The ribs were spread and the pericardium opened, but found to be free of adhesions. The oracle was thin and would not support hemostatic sutures. The superior vena cava was isolated, taped and incised. A clamp was threaded down through the superior vena cava into the oracle and the fragment was removed. This extra cardiac avenue to a chamber of the heart served quite satisfactorily. This is the patient some weeks after operation. A shell fragment and piece of clothing were removed from a lacerated left oracle as shown in the following diagram. The patient had had three massive hemorrhages out through an open chest wound that had become an empyema. A posterior lateral thoracotomy through the empyema exposed a laceration in the pericardium and adherent underlying left oracle at the base of the appendage. The laceration was plugged with clot and the missile surrounded by clothing lay within the oracle. The missile was removed and the oracle sutured without difficulty. The patient did well. The posterior approach to the pericardium and heart with the patient in the ventral decubitus position has advantages at times. On the right side, the inferior vena cava and the posterior aspect of the left or right oracle can be reached through this posterior approach. The patient is on his abdomen. The sixth, seventh or eighth rib is resected and the pericardium is opened. Traction on the pericardium will deliver the heart to view from beneath the obscuring vertebral bodies. The shift of the heart into the opposite hemithorax is a disadvantage of the posterior lateral approach. The shift of heart and mediastinum away from the surgeon is most marked in the lateral decubitus. It is less marked here as the patient is flat on his abdomen and chest. This rentganogram demonstrates the fallacy of depending on ordinary tough films to demonstrate cardiac and mediastinal missiles. More penetrating exposure outlines a missile that would otherwise be missed. Still more penetration clearly discloses the fragment. Neither by x-ray films nor by fluoroscopic examination could this fragment be separated from the heart. Indeed it looked as if it might lie in a herniation of the floor of the right ventricle. The oblique views are often helpful. In this location, division of the sternum often affords better exposure. The skin is marked for a double curved combination trans-sternal and intercostal incision. Only the intercostal portion is made until pericardial exploration indicates the necessity for the additional exposure. Sternum is then divided with a jiggly saw. The pericardium is open transversely down to the phrenic nerve. The Tudor Edwards retractor is adapted for use anteriorly. The heart can then be lifted out of the pericardium to recover the missile from a pericardial abscess. This is the operation just described. Plectrocardiographic tracings are always taken during the operations. The skin is marked for the combined intercostal and sternal dividing incision. Only the intercostal portion is made until the need for extension is established. The internal mammary vessels are divided. The intercostal nerves are blocked with novocaine in oil. Lung is freed from pericardium. Cartilage is divided. Pericardium is opened like peritoneum. Novocaine solution 1% is flushed into the pericardial sac. Prenic nerve. Pericardium split anteriorly to nerve laterally. Note that the heart is not dilated and is readily contained within the pericardial sac. Exploration indicates that sternal section is needed. A jiggly saw is used to divide the sternum. Tudor Edwards retractor is adapted for use here. The heart is dislocated and becomes extremely irregular. The missile is extracardiac in an abscess. The heart is returned to position of optimal function for arrest. Dilation of the heart can be seen. The fragment lay in an abscess containing 18 cc's of pus. The organism was Clostridium Welchie. The fragment is removed. The heart is markedly dilated. Pericardium is washed thoroughly and then closed. A decompression window is left which drains into the plural space. 100,000 units of penicillin are injected into the pericardial sac. The sternum is drilled for wire fixation. Solid reconstruction of the sternum reduces postoperative discomfort and shock. The cartilages are repaired. Pericostal sutures are of cat gut. Plura is not closed. The incision is closed in layers. Electrocardiographic tracings taken during the operation in lead 2 show normal rhythm. Before manipulation, the QRS interval is 0.08 seconds. Incomplete bundle branch block developed as the heart dilated and is accompanied by lengthening of the QRS time to 0.13 seconds and notching of the S wave. Two ventricular extra systoles occur here. Some areas show a wandering pacemaker. The PR interval varies, then it disappears, and nodal rhythm is recorded. Normal rhythm returns again after a rest. The patient has his sutures out on the fourth day. The butterfly adhesive retention is applied. This allows early suture removal. The butterflies are so placed that no tension is exerted in the margins of the incision. The ends of the butterflies are buttressed with adhesive strips. This is a sinophloroscopic study of a missile presumably lodged in the posterior aspect of the chamber of the right ventricle. The rate of movement is slowed by one third and provides an interesting motion pattern study. We are indebted to Professor Barclay of the Nuffield Institute at Oxford for these unique pictures. The basic incision is made and often the optional Y extension added. Intercostal incision is made and the cartilages are divided. The pericardium is opened. The ribs are spread and the heart is exposed. Hemostatic gysuptures are placed on either side of the projected cardiotomy site over the foreign body that has been palpated in the chamber of the right ventricle. These sutures are crossed to affect hemostasis between intracardiac maneuvers. This operation follows. This is a typical rentgenogram of a shell fragment in the chamber of the right ventricle. Compare its extreme anterior position to the pericardial bullet previously presented. It is just as far forward as the previous missile. Yet because it lies to the left of the midline, it can be expected to occupy a position within the ventricle. Removal of this missile follows. The Y extension has been made and the cartilages have been divided. The pericardium is opened. Nobacane is flushed into the pericardial sac. The foreign body can be palpated within the chamber of the right ventricle. The large missile produces a visible bulge in the ventricle. Hemostatic gysuptures are placed about the site for incision. The sutures are placed in an irregular staggered fashion so that all central areas are backed by two rows of sutures. Yet none are placed so as to limit the blood supply of the medial myocardium. Each suture is tied loosely so that the heart does not move on it. This is important in the prevention of bleeding. The epicardium is incised. The chamber is open and bleeds. The fragment slips from the grasp of the forceps. A second clamp assists and the fragment is lifted out. The gysuptures are crossed and tied. Two layers of pericardial grafts are placed over the incision. The pericardium is closed loosely so that blood or effusion can drain into the pleura and not cause cardiac tamponade. A routine closure is made. This is clothing on the missile. The following day the patient is comfortable. This blurred image represents an intraventricular fragment. At right ventricular cardiotomy the missile was pulled from the grasping forceps by the myocardium and escaped into this position in the right oracle. Here is the lateral view. Three months later at left oricular cardiotomy the missile again escaped and moved back into the right ventricle. To recapitulate, in the dorsal decubitus position the heart was opened through an anterior approach. The missile slipped from the forceps and moved into the right oracle. Three months later the oracle was opened through a posterior lateral approach. The fragment was seen and grasped but fell down into the right ventricle. At the third cardiotomy the patient was turned so that the foreign body and apex of his right ventricle were in a dependent position. The foreign body was trapped in this position and successfully removed. This is an electrocardiographic tracing in lead two taken during the removal of the shell fragment from the right ventricle. The first two beats are normal. There is a run of ventricular exorcistiles of 16 seconds duration during the time of the actual intracardiac manipulation and successful removal of the missile. Prompt reversion to normal rhythm is noted in the last three beats of the strips. This is a continuous strip. This operation follows. Here is the third cardiotomy in the same individual. The patient is in the position described in the diagram. The old incisional scar is excised. The previous repair makes this incision less clear anatomically but it is firm. The pericardium is firmly adherent to the myocardium. A flabby herniated area of myocardium is found over the foreign body. The previous cardiotomy site is solid. It has healed well. The previous site is above and medial to this area of damaged myocardium. This damage has been caused by the muscle moving over the underlying fragment. A pedicle of fused pericardium is developed. This will be used as a graft over the incision and will support the weakened area in the damaged myocardium. The hemostatic guy sutures are placed about the projected incision in two irregular rows staggered to avoid central ischemia of the muscle. These are tied to prevent the myocardium from sawing on the sutures. Movement on untied sutures is often associated with hemorrhage. The myocardial incision is started. It is carefully carried down until the endocardium is seen protruding through the incision. A forceps is thrust into the right ventricle of the heart. The missile is repeatedly grasped but escapes from the forceps. Two clamps seize the fragment and it is removed. Hemostatic sutures are crossed and tied. A leak is blocked with a finger and hemostatic suture is placed in the heart with the finger in situ. Two reinforcing pericardial grafts are sutured over the incision. This is the second small pericardial graft. The chest is closed in the usual manner. This was the most sanguine and difficult of the group of intracardiac foreign bodies. Yet blood was replaced very rapidly and the patient at no time lost his effective blood pressure. It will be recalled that the electrocardiograms taken during this time showed multiple extracellulis from varying foci in both ventricles. These led to runs of ventricular tachycardia lasting up to 16 seconds. It will also be recalled that after the foreign body was removed and the manipulation discontinued, the electrocardiogram returned to normal. The two intracardiac operations shown are used in preference to some of the simpler intracardiac manipulations to demonstrate the vigorous handling that the heart will tolerate as long as the surgeon observes certain principles of cardiac surgery. Conversely, the apparently simple maneuver of dislocating the heart was tolerated badly. It does not seem too much to hope that as we come to understand this organ better, we can confidently expect to do many more intracardiac operations. The patient is comfortable the next day.