Right Ventricular Perforation and Pulmonary Embolism With Polymethylmethacrylate Cement After Percutaneous Kyphoplasty
2013; Lippincott Williams & Wilkins; Volume: 127; Issue: 11 Linguagem: Inglês
10.1161/circulationaha.112.144535
ISSN1524-4539
AutoresIgor Gošev, Luigi Nascimben, Pei‐Hsiu Huang, Laura Mauri, Michael L. Steigner, Annette Mizuguchi, Amil M. Shah, Sary F. Aranki,
Tópico(s)Trauma Management and Diagnosis
ResumoHomeCirculationVol. 127, No. 11Right Ventricular Perforation and Pulmonary Embolism With Polymethylmethacrylate Cement After Percutaneous Kyphoplasty Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBRight Ventricular Perforation and Pulmonary Embolism With Polymethylmethacrylate Cement After Percutaneous Kyphoplasty Igor Gosev, MD, Luigi Nascimben, MD, Pei-Hsiu Huang, MD, Laura Mauri, MD, MSc, Michael Steigner, MD, Annette Mizuguchi, MD, Amil M. Shah, MD and Sari F. Aranki, MD Igor GosevIgor Gosev From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Luigi NascimbenLuigi Nascimben From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Pei-Hsiu HuangPei-Hsiu Huang From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Laura MauriLaura Mauri From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Michael SteignerMichael Steigner From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Annette MizuguchiAnnette Mizuguchi From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA , Amil M. ShahAmil M. Shah From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA and Sari F. ArankiSari F. Aranki From the Divisions of Cardiac Surgery and Interventional Cardiology (I.G., P.-H.H., L.M., S.A.), Department of Anesthesiology, Perioperative, and Pain Medicine (L.N., A.M.), Department of Radiology (M.S.), and Division of Cardiovascular Medicine (A.M.S.), Brigham and Women's Hospital, Boston, MA Originally published19 Mar 2013https://doi.org/10.1161/CIRCULATIONAHA.112.144535Circulation. 2013;127:1251–1253A 58-year--old woman was referred to our center for further workup and treatment of a probable polymethylmethacrylate (PMMA) embolism to the right ventricle (RV) and right pulmonary artery. The patient's medical history included hypertension, hypothyroidism, hyperlipidemia, and anxiety. She developed lower back pain ≈1 month before admission and was diagnosed with multiple compression fractures. Ten days before admission, the patient underwent percutaneous kyphoplasty of the T11, T12, and L1 vertebral bodies. A biopsy during that procedure revealed multiple myeloma as the underlying cause of the fractures. No vascular abnormalities were noticed at that time. A day before transfer she was readmitted with chest pain and shortness of breath. She was noted to have diffuse ST segment elevations on her ECG and mildly elevated cardiac troponin. Coronary angiography did not show evidence of obstructive coronary disease. However, fluoroscopy during coronary angiography showed foreign material in the RV and the pulmonary artery (Figure 1 and online-only Data Supplement Movie I). A computed tomography demonstrated foreign material in the RV and the pulmonary artery with a free wall perforation (Figure 2 and online-only Data Supplement Movie II). On arrival to our institution, an echocardiogram showed a hyperechogenic rod-like structure 5 to 6 cm long embedded in the RV free wall with a moderate pericardial effusion (Figure 3 and online-only Data Supplement Movie III).Download figureDownload PowerPointFigure 1. Fluoroscopy during coronary angiography with polymethylmethacrylate fragment (arrow) in the right ventricle and cement in the vertebral body.Download figureDownload PowerPointFigure 2. Chest CT 3-dimensional reconstruction polymethylmethacrylate fragment in the pulmonary artery (short arrow) and right ventricle (long arrow).Download figureDownload PowerPointFigure 3. Echocardiogram of the right ventricle showing a hyperechogenic polymethylmethacrylate fragment (arrow) imbedded in the right ventricular free wall.Endovascular retrieval of the cement fragments was considered, but given the expectation that the embolic material, PMMA cement, would not be pliable enough to allow catheter-based retrieval, the consensus decision was to approach removal surgically. The patient was taken to the operating room. After opening the pericardium, 200 mL of old blood and clot were evacuated. On further inspection, a white colored spear-shaped foreign body penetrating the acute margin of the RV was found with the piece of it penetrating into the diaphragm (Figure 4 and online-only Data Supplement Movie IV). After cardiopulmonary bypass initiation and opening of the right atrium, the foreign body 6 cm in length entangled in the tricuspid valve anterior leaflet cords was removed from the right ventricular cavity (Figure 5 and online-only Data Supplement Movie V). The RV was then repaired with pledgeted 4-0 Prolene suture. Another foreign V-shaped body was retrieved through the right pulmonary artery from the right upper and middle lobe pulmonary artery branches (Figure 6). On uneventful cardiopulmonary bypass termination, the bilateral reactive plural effusions were evacuated. The patient was extubated 1 hour after surgery and was transferred to the step-down unit on the first postoperative day.Download figureDownload PowerPointFigure 4. Polymethylmethacrylate fragment penetrating the acute margin of the right ventricle (arrow).Download figureDownload PowerPointFigure 5. Polymethylmethacrylate fragment 6 cm in length removed from the right ventricular cavity.Download figureDownload PowerPointFigure 6. V-shaped polymethylmethacrylate fragment in the right upper and lower lobe pulmonary artery branches.Percutaneous vertebroplasty and kyphoplasty have become an increasingly common technique for treatment of vertebral compression fractures since its introduction in the late 1980s. Percutaneous kyphoplasty involves creation of a balloon cavity in the vertebral body before injection of PMMA cement to enable a lower pressure deployment and thereby reduce the risk of embolism. Embolism of the PMMA cement is frequently associated with these procedures, occurring in ≤26% of patients in some reports.1,2 The PMMA cement likely enters the venous system through the iliolumbar or epidural veins and migrates centrally to the right heart chambers and pulmonary arteries. On some occasions, migration of larger cement fragments can be seen on fluoroscopy during the procedure. However, patients are frequently asymptomatic, and many cement emboli are found incidentally on subsequent imaging.2Several points are worth considering in this case. Our patient presented with signs and symptoms of pericarditis caused by the protruded RV fragment. We believe that the RV perforation occurred when the hardened cement fragment in the ventricle was pushed through the free wall by the tricuspid valve annulus during cardiac systole. She did develop a moderate pericardial effusion that fortunately did not progress to cause cardiac tamponade. RV perforation has been described previously with management by surgical retrieval of the PMMA cement fragments and repair of the ventricle.3 Endovascular retrieval of a cement fragment embolus in the pulmonary artery without RV damage has also been reported.4 In that case, a rounded cement piece was maneuvered from the pulmonary artery to the femoral vein, where it was retrieved via a surgical cutdown. Although we considered an endovascular approach, the long linear and V-shaped pieces could not be retrieved easily without risk of further fragmentation and embolization or entanglement in the tricuspid valve apparatus, and, importantly, percutaneous repair of the RV puncture site would not be feasible.Small cement emboli typically do not cause symptoms and appear to remain inert over the long term, so routine postprocedure imaging has not been advocated.1,2 Nonetheless, cement embolization and cardiac vascular perforation should be considered in patients presenting with chest pain after percutaneous kyphoplasty.Written consent for the publication was obtained from the patient.DisclosuresNone.FootnotesGuest Editor for this article was Jeffrey A. Brinker, MD.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.112.144535/-/DC1.Correspondence to Igor Gosev, MD, Brigham and Women's Hospital, 75 Frances St, Boston, MA 02115. E-mail [email protected]References1. Venmans A, Klazen CA, Lohle PN, van Rooij WJ, Verhaar HJ, de Vries J, Mali WP. Percutaneous vertebroplasty and pulmonary cement embolism: results from VERTOS II.AJNR Am J Neuroradiol. 2010; 31:1451–1453.CrossrefMedlineGoogle Scholar2. Luetmer MT, Bartholmai BJ, Rad AE, Kallmes DF. Asymptomatic and unrecognized cement pulmonary embolism commonly occurs with vertebroplasty.AJNR Am J Neuroradiol. 2011; 32:654–657.CrossrefMedlineGoogle Scholar3. Lim SH, Kim H, Kim HK, Baek MJ. Multiple cardiac perforations and pulmonary embolism caused by cement leakage after percutaneous vertebroplasty.Eur J Cardiothorac Surg. 2008; 33:510–512.CrossrefMedlineGoogle Scholar4. Bose R, Choi JW. 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