TY - JOUR
AU - , Van Garsse, Leen
AB - Abstract Bone cement leakage is a common complication after percutaneous kyphoplasty. In rare cases, leakage into the venous system occurs, which can be life-threatening, especially when it embolizes the heart. Here, we present a case of cement embolization of the right ventricle with tricuspid valve involvement. A 69-year-old woman with an asymptomatic severe tricuspid valve regurgitation was referred to our department. She had a history of balloon kyphoplasty because of osteoporotic collapsed vertebrae in 2010. Echocardiography showed a foreign body attached to the right ventricle, prolapsing into the right atrium and causing a severe tricuspid valve regurgitation. The foreign body was surgically removed, and the tricuspid valve was replaced with a biological valve. The foreign body was analysed by scanning electron microscopy and element analysis. Zirconium was identified within the foreign body, which is an additive in bone cement used in orthopaedic surgery. Intracardiac cement embolism following percutaneous kyphoplasty is a rare but life-threatening complication. Here, we present a case of tricuspid valve destruction caused by the long-term presence of an intracardiac foreign body, specifically a cement embolus. Foreign body, Right ventricle, Tricuspid valve, Polymethylmethacrylate, Percutaneous kyphoplasty INTRODUCTION Percutaneous kyphoplasty is a minimally invasive technique in which bone cement is injected into a destroyed vertebral body with the objective of reinforcing the vertebrae and subsequently relieving pain. Due to the widespread use of this technique for a variety of indications, a growing number of complications are reported in the literature [1, 2]. The most frequent complication involves bone cement leakage. Cement leakage into the surrounding tissues may be asymptomatic but could potentially cause spinal canal stenosis or nerve root compression. Additionally, cement leakage into the perivertebral venous system can result in pulmonary and intracardiac embolisms, which can cause life-threatening complications. In this report, we present a case of intracardiac cement embolization, resulting in severe tricuspid valve regurgitation, 7 years after percutaneous kyphoplasty. CASE REPORT A 69-year-old woman with severe tricuspid valve regurgitation, which was detected during the preoperative screening for orthopaedic surgery, was referred to our department. The patient did not have any cardiac complaints. Transoesophageal echocardiography showed a foreign body attached to the right ventricle near the location of the tricuspid valve, which caused severe tricuspid valve regurgitation (Fig. 1A and Video 1). The presence of the foreign body as well as the presence of an intrapulmonary and secondary intracardiac foreign body were clearly visible on the coronary angiogram (Fig. 1B and Video 2). The foreign body was removed through a right atriotomy (Fig. 1C and D). The tip of the foreign body was firmly encased in fibrotic tissue into the anterior wall of the right ventricle, just beneath the tricuspid valve. Some of the chordae were attached to the foreign body, and the septal leaflet was destroyed and retracted by repetitive trauma. The tricuspid valve was replaced with a biological valve (Carpentier-Edwards PERIMOUNT Magna Ease®, size 33 mm). The other 2 noted lesions were left in situ, as there was no indication to remove these asymptomatic intracardiac and pulmonary cement emboli. The patient recovered well from surgery despite developing a total atrioventricular block for which a permanent pacemaker was required. Figure 1: View largeDownload slide (A) Transoesophageal echocardiogram showing the foreign body (arrow). (B) Coronary angiogram. (C) Surgical view of the foreign body (arrow). (D) The foreign body after removal. AO: aorta; AV: aortic valve; H: cement particle in heart; L: cement particle in lung; RA: right atrium; RV: right ventricle; TV: tricuspid valve. Figure 1: View largeDownload slide (A) Transoesophageal echocardiogram showing the foreign body (arrow). (B) Coronary angiogram. (C) Surgical view of the foreign body (arrow). (D) The foreign body after removal. AO: aorta; AV: aortic valve; H: cement particle in heart; L: cement particle in lung; RA: right atrium; RV: right ventricle; TV: tricuspid valve. Video 1 Transoesophageal echocardiogram. Video 1 Transoesophageal echocardiogram. Close Video 2 Coronary angiogram. Video 2 Coronary angiogram. Close The resected foreign body was suspected to be a cement embolism, which was plausible because the patient underwent a balloon kyphoplasty for osteoporotic collapsed vertebrae 7 years earlier. During this operation, Palacos cement was injected at levels T12 and L1. The foreign body was analysed with scanning electron microscopy and element analysis. Scanning electron microscopy analysis showed a similar morphology when compared to Palacos cement, the material used during the kyphoplasty (Fig. 2A). Furthermore, element analysis identified the presence of zirconium, which is often added to bone cement to increase radio-opacity and cytocompatibility properties, and to improve fatigue resistance [3]. Figure 2: View largeDownload slide Scanning electron microscopy image of (A) the explanted foreign body and (B) Palacos cement. Figure 2: View largeDownload slide Scanning electron microscopy image of (A) the explanted foreign body and (B) Palacos cement. DISCUSSION In patients treated with either kyphoplasty or vertebroplasty for osteoporotic collapsed vertebrae, cement leakage has been described to occur in 30–65% of patients [4]. Cement leakage into the perivertebral venous system can cause a variety of complications, including rare and life-threatening pulmonary and intracardiac or paradoxal arterial embolisms in the presence of a patent foramen ovale. Although often occurring immediately after the procedure, embolisms can also present as a late complication, years after the initial treatment. As these embolisms are usually small and do not lead to clinically relevant symptoms, the exact number of embolizations remains unclear. The first choice of treatment for symptomatic intracardiac embolism is surgical removal because of the potential complications that can occur. An acute manifestation of intracardiac embolism that requires immediate surgery involves perforation of the cement embolus through the atrial or ventricular wall, causing tamponade [5]. In case of valvular involvement, additional valve repair or replacement may be necessary. With the increased usage of cement in the percutaneous treatment of vertebral compression fractures, a higher rate of intracardiac embolisms due to cement leakage is to be expected. ACKNOWLEDGEMENTS The authors thank Benno Kusters (Pathology), Cyril Camaro (Interventional Cardiology), Saloua El Messaoudi (Imaging Cardiology) and Samiena Alidjan. Conflict of interest: none declared. REFERENCES 1 Wang LJ , Yang HL , Shi YX , Jiang WM , Chen L. Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: a systematic review . Orthop Surg 2012 ; 4 : 182 – 9 . Google Scholar Crossref Search ADS PubMed 2 Shridhar P , Chen Y , Khalil R , Plakseychuk A , Cho SK , Tillman B et al. A review of PMMA bone cement and intra-cardiac embolism . Materials 2016 ; 9 : E821 . Google Scholar Crossref Search ADS PubMed 3 Gillani R , Ercan B , Qiao A , Webster TJ. Nanofunctionalized zirconia and barium sulfate particles as bone cement additives . Int J Nanomedicine 2010 ; 5 : 1 – 11 . Google Scholar Crossref Search ADS PubMed 4 Zhan Y , Jiang J , Liao H , Tan H , Yang K. Risk factors for cement leakage after vertebroplasty or kyphoplasty: a meta-analysis of published evidence . World Neurosurg 2017 ; 101 : 633 – 42 . Google Scholar Crossref Search ADS PubMed 5 Tran I , Gerckens U , Remig J , Zintl G , Textor J. First report of a life-threatening cardiac complication after percutaneous balloon kyphoplasty . Spine 2013 ; 38 : E316 – 18 . Google Scholar Crossref Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Intracardiac cement embolism resulting in tricuspid regurgitation
JF - European Journal of Cardio-Thoracic Surgery
DO - 10.1093/ejcts/ezy233
DA - 2019-02-01
UR - https://www.deepdyve.com/lp/oxford-university-press/intracardiac-cement-embolism-resulting-in-tricuspid-regurgitation-q2hs05mVyW
SP - 366
VL - 55
IS - 2
DP - DeepDyve
ER -