Asymptomatic Cement Embolism in the Right Atrium after Vertebroplasty Using High-Viscosity Cement: A Case Report

Abstract

A 52-year-old woman underwent vertebroplasty for fractures of the T10, T11, and L2 vertebrae secondary to multiple myeloma. She was discharged uneventfully within a week. Nine months later, she was readmitted for syncope. Echocardiography revealed a mass in the right atrium. Magnetic resonance imaging (MRI) revealed a low signal intensity irregular mass (8x7 mm) and a comma-shaped mass (12 mm) in the right atrium. She was prophylactically anticoagulated for the probable emboli. Repeat cardiac MRI performed 2 weeks later showed that the size of the masses remained unchanged. Surgical intervention was not suggested by the cardiothoracic surgeons. Three months later, the patient remained uneventful.

A Review of PMMA Bone Cement and Intra‐Cardiac Embolism

“…Intra-cardiac embolism (ICE) secondary to PMMA leakage could be an incidental finding or it may appear during the procedure, immediately following the procedure, during hospital recovery, or even manifest as a long term complication (ranging from days to years) ( Table 2 , [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ]). The clinical significance of cement emboli as an incidental finding on chest radiographs may not be ignored due to their known long-term sequelae.…”

Acute right atrial and pulmonary artery bone cement mass emboli following vertebroplasty

“…The most lethal complications are cardiac and pulmonary artery embolization. 2 These phenomena can be explained by cement embolus migrating from the vertebral venous plexus to the inferior vena cava, right heart chambers, and pulmonary arterial system. Pulmonary cement emboli after vertebroplasty are not uncommon (1%–23%).…”

“…Pulmonary cement emboli after vertebroplasty are not uncommon (1%–23%). 2 Most cases are asymptomatic, with only 1% presenting with dyspnoea which usually settles with conservative management (oxygen therapy ± anticoagulants and observation). 3 However, for symptomatic cases or patients with central emboli, anticoagulation cannot dissolve the cement or release the right ventricular load, and surgical extraction is mandatory.…”

“…Previous reports of similar cement-related cardiac perforation and pulmonary emboli involved smaller fragments (range, 1–10 cm). 2 , 4 – 7 Only one article reports a patient with acute respiratory distress during the vertebroplasty procedure requiring emergency surgery for a PA embolus. 8 …”

“…Moreover, bone cement leakage is the main complication and has been reported to be as high as 24%. 2 Cement leakage can result in lethal complications such as pulmonary and cardiac embolization. This case highlights an uncommon but a serious early complication following vertebroplasty.…”