Ventricular Tachycardia as the Sentinel Event for Intracardiac Cement Embolization: a Case Report on de-escalation to Conservative Management After Iatrogenic Fragmentation Following Percutaneous Retrieval Attempt

Background Cement-augmented pedicle screw fixation is an established technique in complex spinal surgery, but intracardiac and pulmonary cement embolization remain feared complications. Management is poorly standardized, particularly when percutaneous retrieval is attempted and fails. Case summary A 58-year-old woman with severe scoliosis underwent long-segment vertebral arthrodesis (T3–S1) at multiple levels. Intraoperative ventricular arrhythmia prompted postoperative imaging, which revealed a linear cement embolus spanning the right ventricular outflow tract and crossing the pulmonary valve. Percutaneous retrieval was attempted due to high-risk anatomical positioning but resulted in cement fragmentation and distal embolization into bilateral pulmonary segmental arteries. Following multidisciplinary reassessment confirming the absence of hemodynamic compromise, the strategy was de-escalated to anticoagulation and close surveillance. The patient recovered uneventfully. Discussion This case uniquely illustrates the management decision pathway when percutaneous retrieval fails. Fragmentation with distal embolization away from the pulmonary valve may represent an acceptable procedural endpoint permitting de-escalation to conservative management. The intraoperative arrhythmia served as a critical sentinel event guiding early diagnosis in the context of cement-augmented pedicle screw fixation, which is underrepresented in bone cement embolization literature compared to vertebroplasty/kyphoplasty.