title: Intracardiac bone cement embolism as a complication of vertebroplasty: management strategy.
abstract: Vertebroplasty carries multiple complications due to the leakage of polymethylmethacrylate (PMMA) into the venous system through the iliolumbar or epidural veins. The rate of venous cement complications may vary from 1 to 10 %, with cement extravasation into the venous system in 24 % of patients. Emboli may further migrate into the right heart chambers and pulmonary arteries. Patients may vary in presentation from asymptomatic or symptoms such as syncope to life-threatening complications.
  
  
  
  We present a case of a 57-year-old lady diagnosed with osteoporosis who underwent a staged antero-posterior fixation with PMMA vertebroplasty of progressive thoraco-lumbar kyphosis caused by osteoporotic fractures to T12, L1 and L2 vertebral bodies. Four weeks after the operation, the patient developed symptoms of left-sided chest pain, tachycardia and tachypnea. CT pulmonary angiogram (CTPA) found a high-density material within the right atrium, whilst ECHO demonstrated normal systolic function. The patient was commenced on enoxaparin at therapeutic dose of 1.5 mg/kg for 3 months and remained asymptomatic. Follow-up ECHO found no change to the heart function and no blood clot on the PMMA embolus.
  
  
  
  Factors influencing the decision about conservative treatment included symptoms, localisation of the embolus, as well as time lapse between vertebroplasty and clinical manifestation. Patients that are commonly asymptomatic can be treated conservatively. The management of choice is anticoagulation with low-molecular-weight heparin or warfarin until the foreign body epithelialises and ceases in becoming potentially thrombogenic. Symptomatic patients with thrombi in the right atrium are commonly managed via percutaneous retrieval, whilst those with RV involvement or perforation are commonly managed with surgical retrieval. Management of individual patients should be based on individual clinical circumstances. Patients presenting with intracardiac bone cement embolism related to spinal procedures require thorough clinical assessment, cardiology input, and if required, surgical intervention.
authors.affiliation: The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Queens Medical Centre, D Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
authors.forename: Catherine
authors.initials: C
authors.lastname: Hatzantonis
authors.affiliation: The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Queens Medical Centre, D Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK.
authors.forename: Marcin
authors.identifier: 0000-0001-7224-4272
authors.initials: M
authors.lastname: Czyz
authors.affiliation: Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Renata
authors.initials: R
authors.lastname: Pyzik
authors.affiliation: The Centre for Spinal Studies and Surgery, Nottingham University Hospitals NHS Trust, Queens Medical Centre, D Floor, West Block, Derby Road, Nottingham, NG7 2UH, UK. bronek.boszczyk@nuh.nhs.uk.
authors.forename: Bronek M
authors.initials: BM
authors.lastname: Boszczyk
mesh_terms: D000925:Anticoagulants / Q000627:therapeutic use; D001843:Bone Cements / Q000009:adverse effects* / Q000627:therapeutic use; D004617:Embolism / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D017984:Enoxaparin / Q000627:therapeutic use; D005260:Female; D006331:Heart Diseases / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000209:etiology; D006801:Humans; D008875:Middle Aged; D058866:Osteoporotic Fractures / Q000601:surgery; D019904:Polymethyl Methacrylate / Q000009:adverse effects / Q000627:therapeutic use; D054854:Vertebroplasty / Q000009:adverse effects* / Q000379:methods
chemical_list: D000925:Anticoagulants; D001843:Bone Cements; D017984:Enoxaparin; D019904:Polymethyl Methacrylate
keywords: Bone cement embolism; Intracardiac embolism; Vertebroplasty