Intramyocardial shotgun pellets diagnosed on initial emergency room chest X-ray: case report. The diagnosis of retained intracardiac missile is usually made at thoracotomy or fluoroscopy. Close inspection of plain chest X-rays may reveal blurring of radiopaque objects that are moving with the beating heart. In a gunshot wound victim who is initially stable, observation of this phenomenon should prompt a very high index of suspicion for cardiac injury. Invasive hemodynamic monitoring is indicated, and thoracotomy should be performed if penetrating cardiac injury is confirmed. 