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Bone cement embolism into the right heart

Open AccessPublished:October 04, 2022DOI:https://doi.org/10.1016/j.xjtc.2022.09.017
      Figure thumbnail fx1
      Intracardiac embolization of bone cement into the right heart.
      Bone cement embolization is a well-documented complication of percutaneous vertebroplasty. Cardiac embolization is not an infrequent condition that may sometimes require surgical intervention.
      Percutaneous vertebroplasty with the use of bone cement is a widely performed minimally invasive orthopedic procedure for treating osteolytic vertebral metastases and osteoporotic vertebral fractures. One of the main complications associated with percutaneous bone cement injection is cement leakage, either into the paravertebral tissue or, less frequently, into the perivertebral venous plexus, which may result in embolization into the right heart or pulmonary vasculature. In this report, we present a case of intracardiac bone cement embolism after percutaneous vertebroplasty.

      Case Report

      This is a 76-year-old female patient with a history of osteoporotic vertebral compression fracture, for which she had received percutaneous vertebroplasty of the L3–L5 vertebra with methyl methacrylate 2 months before presentation (Figure E1). The patient had been experiencing intermittent chest tightness and dyspnea since the procedure, so she presented to the cardiology clinic for evaluation. An echocardiogram showed an echogenic mass within the right atrium/ventricle (Figure 1, A), as well as the presence of moderate tricuspid insufficiency. Radiograph of the chest (Figure 1, B) and computed tomography (Figure 1, C) also revealed a linear-shaped hyperattenuated lesion extending from the right atrium into the right ventricle. Fragments of hyperattenuated lesions were also seen in the branches of the right pulmonary artery (Figure E2). In light of her recent surgical history, bone cement cardiac embolism was suspected.
      Figure thumbnail gr1
      Figure 1A, Echocardiography showed the presence of an echogenic linear mass within the right atrium and ventricle of the heart (white arrow). B, A linear hyperattenuated lesion was found on the radiograph of the chest (white arrow). C, Computed tomography also clearly demonstrated that there was a radio-opaque mass extending from the right atrium into the right ventricle (white arrow).
      Upon admission, physical examination was unremarkable except for a grade II systolic murmur at the right lower sternal border. Subsequent surgical extraction of the cement was successfully performed through a median sternotomy under cardiopulmonary bypass. Upon right atriotomy, it was noted that the bone cement was densely adhered to the tricuspid valve leaflet (Video 1), and tricuspid valve replacement was required due to irreparable leaflet damage (Figure 2). The patient was admitted to the intensive care unit for postoperative monitoring and was subsequently transferred to the general ward the next day. In accordance with the institutional policy of the institutional review board (IRB) or equivalent ethics committee of the National Taiwan University Hospital, the IRB committee of the National Taiwan University waives the need for IRB approval and patient informed consent for case report of a single patient, as long as the article does not contain any patient identifiable information.
      Figure thumbnail gr2
      Figure 2The embolized bone cement was successfully extracted. The cement was densely adhered to the tricuspid valve leaflet. TV, Tricuspid valve.

      Discussion

      Bone cement leakage and embolization is a well-documented complication of percutaneous vertebroplasty, with a reported incidence of 4.6%.
      • Choe D.H.M.E.
      • Ahrar K.
      • Truong M.T.
      • Madewell J.E.
      Pulmonary embolism of polymethyl methacrylate during percutaneous vertebroplasty and kyphoplasty.
      ,
      • Song Y.
      • Huang X.
      • Wu L.
      Removal of intracardiac bone cement embolism after percutaneous kyphoplasty: a case report.
      Potential risk factors for cement embolisms include osteoporotic or osteolytic fracture, injection of cement in large amounts, and under high injection pressure, etc.
      • Zhu S.Y.
      • Zhong Z.M.
      • Wu Q.
      • Chen J.T.
      Risk factors for bone cement leakage in percutaneous vertebroplasty: a retrospective study of four hundred and eighty five patients.
      Although greater injection pressure has generally been considered as a risk factor,
      • Duran C.
      • Sirvanci M.
      • Aydogan M.
      • Ozturk E.
      • Ozturk C.
      • Akman C.
      Pulmonary cement embolism: a complication of percutaneous vertebroplasty.
      ,
      • Wang L.J.
      • Yang H.L.
      • Shi Y.X.
      • Jiang W.M.
      • Chen L.
      Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: a systematic review.
      there is currently lack of evidence to suggest what injection pressure increases risk of cement embolization. The injection pressure is affected by multiple factors, including the technique and equipment used for injection, viscosity of the cement before injection, site of injection, severity and etiology of the fracture, etc.
      • Kim H.J.
      • Chung S.W.
      • Lee S.H.
      • Park C.H.
      • Shin Y.H.
      • Lee S.Y.
      • et al.
      Asymptomatic pulmonary cement embolism after cement-augmented pedicle screw instrumentation: a case Report.
      In our case, the amount of injected cement was unknown. However, in a retrospective study by Hsieh and colleagues,
      • Hsieh M.K.
      • Kao F.C.
      • Chiu P.Y.
      • Chen L.H.
      • Yu C.W.
      • Niu C.C.
      • et al.
      Risk factors of neurological deficit and pulmonary cement embolism after percutaneous vertebroplasty.
      the authors reported an increased risk of pulmonary embolism with >7 cc of injected cement compared with <3.5 cc (0.9% vs 0%, P < .01). However, there have been reports of cement embolism with injected volume as little as 1.5 cc.
      • Kim H.J.
      • Park E.S.
      • Lee S.H.
      • Oh T.H.
      • Park C.H.
      • Shin Y.H.
      Cardiac perforation caused by cement embolus after cement-augmented pedicle screw instrumentation: a case of report.
      This can again be explained by the fact that the occurrence of cement leakage and subsequent embolization is multifactorial, and risk assessment should be individualized.
      Our patient's symptoms developed insidiously over the course of weeks, but for the majority of patients with cement embolization, they remain asymptomatic. For those with symptoms, the onset is highly variable. Whereas some patients develop dyspnea and chest pain immediately after cement injection, there were cases in which patients develop symptoms months or even years after the procedure.
      • Leitman D.
      • Yu V.
      • Cox C.
      Investigation of polymethylmethacrylate pulmonary embolus in a patient ten years following vertebroplasty.
      For cases with no symptoms as well as small and peripherally located cement emboli, they can be managed conservatively with anticoagulants, whereas some patients may require surgery, including those with tricuspid valve dysfunction, right ventricular perforation, and large pulmonary embolism causing hemodynamic instability.
      • Krueger A.
      • Bliemel C.
      • Zettl R.
      • Ruchholtz S.
      Management of pulmonary cement embolism after percutaneous vertebroplasty and kyphoplasty: a systematic review of the literature.
      Previous literature has reported the retrieval of right atrial cement fragments through percutaneous approach; however, there is a potential risk of causing further fragmentation and distal embolization, as well as causing valvular injury.
      • Tran I.
      • Gerckens U.
      • Remig J.
      • Zintl G.
      • Textor J.
      First report of a life-threatening cardiac complication after percutaneous balloon kyphoplasty.
      Therefore, the optimal interventional should be individualized based on the size/location of the bone cement, presence of valvular or ventricular injury, and extent of the embolization, as well as the risk of the procedure and its associated complications.

      Conclusions

      Bone cement embolization is a well-documented complication of percutaneous vertebroplasty with methyl methacrylate, and disease manifestation may vary considerably depending on the size/location/associated valvular dysfunction, etc. Postoperative surveillance with a radiograph of the chest has been proposed by some experts, although its sensitivity may be limited when compared with computed tomography or echocardiography. Most important of all, clinicians should keep in mind that cardiac embolization is not an infrequent condition that may sometimes require surgical intervention.

      Supplementary Data

      • Video 1

        The bone cement was retrieved under partial cardiopulmonary bypass. Upon right atriotomy, a string-shaped piece of cement was seen adhered to the tricuspid valve, and was subsequently removed carefully with DeBakey forceps. Video available at: https://www.jtcvs.org/article/S2666-2507(22)00519-3/fulltext.

      Appendix E1

      Figure thumbnail fx3
      Figure E1Computed tomography image showing bone cement in the lumbar vertebra (L3-L5).
      Figure thumbnail fx4
      Figure E2Computed tomography image showing small fragment of bone cement within branch of the right pulmonary artery (white arrow).

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