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Ann Thorac Surg 2009;87:299-301. doi:10.1016/j.athoracsur.2008.05.074
© 2009 The Society of Thoracic Surgeons
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Case Reports

Cardiac Tamponade and Pulmonary Embolism as a Complication of Percutaneous Vertebroplasty

Baris Caynak, MD, Burak Onan, MD*, Ertan Sagbas, MD, Cihan Duran, MD, Belhhan Akpinar, MD

Department of Cardiovascular Surgery and Radiology, Florence Nightingale Hospital, Istanbul Bilim University, Istanbul, Turkey

Accepted for publication May 27, 2008.

* Address correspondence to Dr Onan, Mazharbey cad. Atilay sok. Memil apt 26/14 Göztepe, Kadikoy, Istanbul, 34730, Turkey (Email: burakonan{at}hotmail.com).


Dr Akpinar discloses a financial relationship with Medtronic.

 

   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
Percutaneous vertebroplasty is a useful and safe therapeutic intervention to stabilize vertebral fractures. Rarely, cement leakage into the paravertebral venous system may result in embolization of its particles into the right cardiac chambers and pulmonary artery. We experienced a case of a 64-year-old woman who was diagnosed through echocardiography as having cardiac tamponade. Previously, the patient was treated for pulmonary cement embolization after percutaneous vertebroplasty. Prompt diagnosis and urgent surgery, in which a few linear cement particles of 1-cm to 2-cm long were discovered within the pericardial space, which resulted in a favorable outcome.

Percutaneous vertebroplasty (PV) is a useful and safe therapeutic intervention in which vertebral compression fractures are stabilized by the injection of bone cement or polymethyl methacrylate into the collapsed vertebral bodies [1]. However, it is unusual that embolization of cement particles into venous circulation can cause cardiac injury and pericardial fluid collection. Although cardiac, thoracic, and general surgical procedures can be complicated with fatal pericardial effusions, orthopedic surgery takes very uncommon place in the cause of the cardiac tamponade. Here the authors present a case with delayed cardiac tamponade and pulmonary cement embolization after PV.

A 64-year-old woman was admitted to the emergency room with progressive dsypnea that she had suffered with for 6 days. The patient was also complaining of chest discomfort that was radiating to her neck and right arm. In her medical history, 2 months ago, she underwent a PV for fractured vertebral bodies between T4 and T9. After the PV, she was treated for pulmonary cement embolism that was diagnosed with a computerized tomographic scan. The computed tomographic chest scan images revealed multiple radio-opaque linear deposits in the paravertebral azygous veins and the distal branches of both pulmonary arteries. It also showed embolized cement particles in the right cardiac chambers, but no pericardial fluid collection (Fig 1). Thus, she was treated with anticoagulation and pulmonary physiotheraphy, and she was uneventfully discharged. Nevertheless, the patient was readmitted with dyspnea.


Figure 1
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  		Fig 1. Preoperative computed tomographic scans demonstrate linear radiodense deposits (arrows) in the (A) right cardiac chambers and the (B) distal branches of the right pulmonary artery after percutaneous vertebroplasty.

 
On arrival, all periferic arteries were palpable. Pulse rate and saturation level were 115 beats per minute and 95%, respectively. Cardiac markers for ischemia were negative without any electrocardiographic changes. Platelet count, hemoglobin, and D-dimer levels were all found within normal limits. A chest roentgenogram obtained on admission showed an enlarged cardiothoracic index. Then the patient's general status detoriated and hemodynamic unstability complicated her presentation. On diagnosis, transthoracic echocardiography revealed cardiac tamponade in which all four cardiac chambers are compressed by pericardial collection, especially the anterior side of both ventricles. Thus, an emergent intervention to relieve tamponade was performed. There was 600 mL of hemorrhagic fluid that was drained from the pericardial space with a subxiphoidal midline insicion. In addition, a few free-floating, thin, 1-cm to 2-cm long linear cement particles were perioperatively discovered (Fig 2). There was no active bleeding detected during exploration.


Figure 2
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  		Fig 2. Image demonstrates thin, linear cement particles discovered perioperatively within the effusion from the pericardial space.

 
The patient's postoperative course was uneventful. We speculated that this delayed tamponade was caused by linear cement particles within the right cardiac chambers. Pathologic evaluation of the samples from pericardial fluid confirmed defibrinated blood and cement particles.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
The PV procedure entails the percutaneous injection of bone cement into the destructed vertebral body that attempts to stabilize the fracture [1]. It is an accepted minimally invasive procedure for the treatment of various vertebral diseases, such as osteoporotic collapse, osteolytic metastasis, and multiple myeloma. Although cardiac tamponade, as the most frequent pericardial emergency, is one of the vital complications of different cardiothoracic procedures, PV has been previously published in literature as a rare cause of cardiac injury attributable to cement embolization [2–4]. Cement use in PV is a safe method that increases mechanical strength of the destructed vertebral body. Nevertheless, cement leakage outside the bone can cause devastating cardiovascular complications if venous embolization occurs. The incidence of pulmonary cement embolization during PV has been reported in up to 6.8% of cases [3, 5]. It is technically recommended that cement should have an appropriate viscosity, and be applied under radiological guidance to detect leakage early during the procedure [6]. Also, special attention should be paid during multi-level PV, which has a higher risk of pulmonary embolism [7].

The patient in the current case previously underwent a PV procedure and was diagnosed with computed tomographic scanned imaging as having a pulmonary cement embolism. Then the echocardiographic evaluation revealed cardiac tamponade. Due to the absence of major pulmonary artery involvement, a midline subxiphoidal approach was preferred. The diagnosis of cement injury causing pericardial effusion was confirmed by perioperative findings. The patient was treated surgically with a favorable outcome. The mechanism of cardiac tamponade in this patient is not clear. However, it can be speculated that this could be a late tamponade due to direct injury of the cardiac chambers during PV procedure that involves cement injection. A second explanation can be an injury to the right chambers of the heart caused by the linear cement segments inside. In this case, it is perioperatively discovered that defibrinated blood in the pericardial space involving cement particles complicated the patient's outcome after the PV was performed.

We believe the cases of only 3 patients have been reported concerning cardiac perforation after PV. The first report was made in 2005. Kim and colleagues [2] reported a case of cardiac perforation caused by acrylic cement as a rare complication of PV. The second case was published by Lim and colleagues [3], in which multiple cardiac perforations and pulmonary embolism due to cement leakage were treated surgically. This report is quite similar to ours, showing the same pathophysiology, but they presented a repair for the perforated free wall of the right ventricle and removed cement particles from the right main pulmonary artery [3]. The last report included the surgical repair of cardiac perforation, as well as tricuspid insufficiency [4].

This report draws attention to the occurrence and clinical behavior of pulmonary cement embolization after PV. It can be diagnosed with thoracic computed tomography and treated with anticoagulation, analgesics, bed rest, and oxygenation, if necessary [8]. In suspected cases, transthoracic echocardiography is a safe modality to evaluate hemodynamic instability. When cardiac tamponade is revealed, an urgent intervention, pericardiocentesis, or pericardiotomy should be performed. Our experience showed that cement embolization to the distal branches of pulmonary arteries can be managed medically. On the other hand, a subxiphoidal approach to releive cardiac tamponade is reasonable in the absence of an active bleeding or massive pulmonary embolization. In cases with additional cardiac pathologies, such as multiple cardiac perforations, valvular insufficiency, or severe pulmonary embolism with heart failure, an emergent open cardiac surgery should be applied.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Phillips FM. Minimally invasive treatments of osteoporotic vertebral compression fractures Spine 2003;28(Suppl 15):S45-S53.[Medline]
  2. Kim SY, Seo JB, Do KH, Lee JS, Song KS, Lim TH. Cardiac perforation caused by acrylic cement: a rare complication of percutaneous vertebroplasty AJR Am J Roentgenol 2005;185:1245-1247.[Free Full Text]
  3. Lim SH, Kim H, Kim HK, Baek M-J. Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty Eur J Cardiothorac Surg 2008;33:510-512.[Medline]
  4. Son KH, Chung JH, Sun K, Son HS. Cardiac perforation and tricuspid regurgitation as a complication of percutaneous vertebroplasty Eur J Cardiothoracic Surg 2008;33:507-508.[Abstract/Free Full Text]
  5. Duran C, Sirvanci M, Aydogan M, Ozturk E, Ozturk C, Akman C. Pulmonary cement embolism: a complication of percutaneous vertebroplasty Acta Radiologica 2007;48:854-859.[Medline]
  6. Cotten A, Dewatre F, Cortet B, et al. Percutaneous vertebroplasty for osteolytic metastases and myeloma: effects of the percentage of lesion filling and the leakage of methyl methacrylate at clinical follow-up Radiology 1996;200:525-530.[Abstract/Free Full Text]
  7. Jang JS, Lee SH, Jung SK. Pulmonary embolism of polymethylmethacrylate after percutaneous vertebroplasty: a report of three cases Spine 2002;27:E416-E418.[Medline]
  8. Baumann A, Tauss J, Baumann G, Tomka M, Hessinger M, Tiesenhausen K. Cement embolization into the vena cava and pulmonal arteries after vertebroplasty: interdisciplinary management Eur J Vasc Endovasc Surg 2006;31:558-561.[Medline]



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[Abstract] [Full Text] [PDF]

This Article
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