A rare cause of pericardial effusion due to intracardiac cement embolism

A 58-year-old female patient was transferred to our department with a suspected acute coronary syndrome. The patient developed angina pectoris and dyspnoea 1 day after kyphoplasty for fracture of the lumbar spine (L2 + L4). Bone cement on a polymethylmethacrylat (PMMA)-basis was injected. The blood samples showed elevated levels for troponin and D-dimer. The ad hoc performed coronary angiography showed no relevant stenosis but unidentifiable radiopaque formations were seen (Panel A, circles). The therefore performed tomography of the chest revealed multiple embolism in the pulmonary arteries due to bone cement leakage (Panel B, circle). In addition, the Echocardiography showed a dense elongated intracardial formation in the right ventricle corresponding to a cement embolism (Panel C). We discussed the case extensively in the heart team and decided on a conservative approach and anticoagulation. Four days later a routinely performed echocardiography and a tomography of the chest showed a pericardial effusion and a perforation of the right ventricular wall (Panel D). The patient was urgently transferred to cardiac surgery. A median sternotomy was performed and a 5 cm × 2 mm cement embolus was extracted as well as the site of perforation overstitched (Panels E and F). After a prolonged hospital stay, the patient could be transferred to a rehabilitation centre. Bone cement embolism after kyphoplasty is a rare but serious and potential life-threatening complication. Intracardial embolism is even more rarely, and the optimal treatment of these patients remains unclear. The need for surgical extraction is an individual decision that should be evaluated from case to case.