Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty: Two Cases reports

Two cases of Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty have been published in the journal Orthopedic Surgery.

Percutaneous vertebroplasty (PVP) is a minimally invasive surgical technique in which polymethyl methacrylate (PMMA) is injected into the weakened vertebral body to strengthen it. However, this procedure is associated with various complications, the most common being cement leakage. Cardiac perforation caused by cement escape into the venous system is another complication, which is rare but potentially life-threatening even if not treated promptly.

Authors have reported two elderly patients who developed cardiac perforation caused by cement escape into veins following PVP.

Patient 1

• A 78year female patient presented with a 7-day history of lower back pain and limited movement. She had a history of atrial fibrillation, nephropyelitis, and serious osteoporosis. Magnetic resonance imaging (MRI) revealed a compression fracture of the L4 vertebral body.

The patient underwent PVP, in which 6 mL of PMMA cement was directly injected into the fractured vertebral body. Side and anteroposterior monitoring revealed venous and spinal canal without cement leakage.

Seventeen hours later, the patient experienced retrosternal pain with epigastric pain. Electrocardiogram (ECG) analysis showed ST-segment elevation of the inferior and anterior wall. Computed tomography (CT) and transthoracic echocardiography (TTE) analyses revealed a hyperechoic linear foreign object in the inferior vena cava and right atrium, which were accompanied by massive pericardial effusion associated with cardiac tamponade. ECG monitoring revealed tachycardia (140 beats/min) and a blood pressure drop to 76/36 mm Hg.

During urgent open-heart surgery, pericardium opening revealed about 300 mL of blood. After opening the atrial surface, a needle-shaped cement (about 50 mm) abutting the right atrial surface inferior vena cava was revealed and removed. Opening the pleura revealed 1100 mL of blood, which was evacuated. The patient recovered well and was discharged 33 days after the operation.

Patient 2

• A 79-year-old female presented with a 5-day history of lower back pain and limited movement. The patient had a history of hypertension and serious osteoporosis. MRI revealed the T7 and T11 vertebral bodies compression fracture.

The patient underwent PVP, in which 2 and 5 mL of PMMA cement were injected into the T7 and T11 vertebral bodies, respectively. Side and anteroposterior monitoring found no venous or spinal canal cement leakage. Fourteen hours later, the patient suddenly drifted into unconsciousness associated with incontinence and limb dyspraxia. Subsequent ECG revealed a blood pressure drop to 55/38 mmHg and a saturation level of 85%, accompanied by low cardiac sound and moist cold skin. ECG also revealed frequent ventricular extrasystole. TTE revealed abnormal echo and small pericardial effusion. CT scanning revealed a hyperechoic linear foreign object in the right atrium, and multiple linear hyperdensities within remote pulmonary arteries. Brain CT revealed ischemic necrosis and cerebral malacia.

During urgent open-heart surgery, pericardium opening revealed massive hemorrhaging. After opening the right atrial surface, a U-type cement (about 60 mm) perforating the ventricular wall on the right side of right atrioventricular groove was revealed and removed. Postsurgical arterial blood gas analysis revealed a pH of 7.49, PaO2 of 47 mmHg, PaCO2 of 41 mmHg, and an oxygenation index (OI) of 220, which is attributable to the patient's pulmonary embolism. The patient entered hypoxemia and failed to wean from mechanical ventilation. Endotracheal intubation was removed upon OI improvement on the day 7 after the operation. The patient recovered well and was discharged 24 days after the operation.

The authors concluded that although PVP is a safe and minimally invasive surgical technique, it is associated with various serious complications. PMMA cement escape into the cardiac system may trigger life-threatening complications. For patients with chest pain and tachypnea, chest radiographs should be performed immediately to determine if there is cement leakage and begin treatment as early as possible.

Appropriate timing of surgical operation, meticulous surgical procedures, early intraoperative and postoperative monitoring of cement leakage may improve outcomes of patients with such complications. 

Further reading :

Cardiac Perforation Caused by Cement Embolism after Percutaneous Vertebroplasty: A Report of Two Cases

DOI: 10.1111/os.13192