Ultra-Delayed Intracardiac Cement Embolism After Percutaneous Vertebroplasty: A Case Report and Review of Management Strategies

Summary

A rare case of ultra-delayed intracardiac bone cement embolism detected 2.5 years after vertebroplasty is presented. Diagnostic imaging, surgical removal under cardiopulmonary bypass, and concurrent coronary artery bypass grafting are demonstrated.

Abstract

Cardiac cement embolism is a rare but potentially life-threatening complication of percutaneous vertebroplasty, usually occurring during or shortly after the procedure. Delayed presentations remain poorly recognized. Here, we report a rare case of intracardiac bone cement embolism 2.5 years after vertebroplasty. A 76-year-old man with a history of lumbar vertebroplasty presented with progressive exercise intolerance and intermittent chest pain. Transthoracic echocardiography and cardiac computed tomography angiography revealed three rod-shaped, high-density foreign bodies in the right ventricle, one of which was embedded in the ventricular myocardium. Coronary angiography demonstrated severe stenosis of the left anterior descending artery. Given the risks of cardiac perforation and coexisting coronary artery disease, simultaneous surgical removal of the cement emboli and coronary artery bypass grafting were performed under cardiopulmonary bypass. All foreign bodies were successfully removed, and the right ventricular wall was reinforced. The patient recovered uneventfully, with resolution of symptoms and preserved cardiac function during 6 months of follow-up. This report highlights the possibility of ultra-delayed and asymptomatic intracardiac cement embolism after vertebroplasty. Long-term cardiovascular surveillance may be warranted in patients with a history of vertebroplasty presenting with unexplained cardiopulmonary symptoms. Although earlier post-vertebroplasty imaging was unavailable, the embolic route likely traversed the pulmonary circulation before lodging in the right ventricle. Given the asymptomatic latency, selective chest imaging may aid early detection in patients with high-risk leakage patterns, though routine screening remains impractical.

Introduction

Percutaneous vertebroplasty (PVP) is a widely used minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures. By injecting polymethylmethacrylate bone cement into the collapsed vertebral body, PVP effectively restores vertebral stability and provides rapid pain relief¹. Despite its clinical benefits, cement leakage remains a recognized complication, with reported incidences varying widely depending on detection methods and cement properties².

Most cement leakage events are clinically silent and confined to paravertebral soft tissue, intervertebral discs, or....

Protocol

This study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of The Second People's Hospital of Liaocheng (approval number: XY2024-LC-038). Written informed consent was obtained from the patient for publication of this case report and accompanying images. The steps of the protocol are presented in Supplementary Figure 1.

1. Preoperative evaluation

1. Transthoracic echocardiography was performed to identify intracardiac foreign bodies and assess cardiac function.
2. Cardiac CT angiography was conducted to determine the size, shape, and locat....

Results

Diagnostic imaging confirmed three rod-shaped intracardiac cement emboli, with one embedded in the RV myocardium, and severe LAD artery stenosis, with paravertebral cement suggesting a venous migration route. All emboli were successfully removed via. CPB-assisted right ventriculotomy, followed immediately by LIMA-to-LAD grafting. The total operative duration was 215 min, with a CPB time of 112 min and an aortic cross-clamp time of 78 min. The patient was extubated on postoperative day 1 and transferred from the .......

Discussion

Cardiac cement embolism is a rare but serious complication of PVP. Most reported cases occur acutely or within a short period after surgery and are associated with obvious cardiopulmonary symptoms^4,5,7. In contrast, the present case demonstrates that intracardiac cement embolism can remain asymptomatic for an extended period and be detected more than 2 years after the initial procedure, expanding the known clinical spectrum of t.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Aspirin	Bayer	www.bayer.com	Antiplatelet agent used to maintain coronary graft patency
Beta-blocker	Institution-specific supplier	www.astrazeneca.com	Used for postoperative cardiovascular protection
Cardiopulmonary bypass system	Getinge	www.getinge.com/int/products/extracorporeal-life-support/cardiopulmonary-bypass/	Full perfusion system with oxygenator and arterial filter
Clopidogrel	Sanofi	www.sanofi.com	Used for short-term dual antiplatelet therapy
Cold crystalloid cardioplegia solution	Institution-specific supplier	N/A	Used for myocardial protection and induction of cardiac arrest
Heparin sodium	Pfizer	NDC 0069-0057-01*	Systemic anticoagulant used during cardiopulmonary bypass
Left internal mammary artery harvest set	Medtronic	www.medtronic.com	Instruments used for harvesting the left internal mammary artery
Microknife	Fine Science Tools	10056-12	Used for coronary arteriotomy and fine surgical dissection
Microscissors	Fine Science Tools	14060-09	Used for sharp dissection around embedded cement fragments
Microsurgical forceps	Fine Science Tools	11003-12	Used for extraction of intracardiac cement emboli
Papaverine hydrochloride	Pfizer	www.pfizer.com	Applied to prevent left internal mammary artery graft spasm
Polymethylmethacrylate (PMMA) bone cement	Heraeus Medical	66004906 (PALACOS R+G)	Bone cement used during vertebroplasty
Polypropylene suture, 7-0	Ethicon	8701H (PROLENE 7-0)	Used for left internal mammary artery-to-left anterior descending artery anastomosis
Protamine sulfate	Pfizer	NDC 0069-0925-01	Used to reverse heparinization after cardiopulmonary bypass
Statin	Institution-specific supplier	www.pfizer.com	Used for long-term secondary prevention after coronary artery bypass grafting
Surgical felt pledgets	B. Braun	1021355	Used for reinforcement of right ventricular wall repair
Transesophageal echocardiography system	GE HealthCare	www.gehealthcare.com/products/ultrasound/cardiovascular-ultrasound	Used intraoperatively to localize cement emboli and confirm complete removal