Woman with chest pain.

Abstract

A 64-year-old woman presented to the emergency department with acute retrosternal chest pain with radiation to the neck for 2 hours. She had a history of percutaneous vertebroplasty for a third lumbar vertebral compression fracture 4 days previously. On examination, the chest pain character changed to intermittent sharp pain. The electrocardiogram revealed normal sinus rhythm. The troponin I concentration was 0.059 ng/mL. Point-of-care ultrasound scans showed a linear hyperechoic shadow in the right ventricle with the tip penetrating the pericardium (Figure 1, arrows; Video E1, available at http://www.annemergmed.com) and a floating hyperechoic shadow in the inferior vena cava (Figure 2, arrowhead; Video E2, available at http://www.annemergmed.com). Computed tomography scans of the chest (Figure 3) and abdomen (Figure 4) confirmed the diagnosis.Figure 2The sagittal ultrasound image of the inferior vena cava shows a floating hyperechoic shadow (arrowhead) inside the inferior vena cava.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Computed tomography image of the chest reveals a hyperdense linear foreign body in the right ventricle that penetrated the myocardium with minimal hemopericardium.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Computed tomography image of the abdomen reveals cement filling in L3 vertebral body and cement leakage into the inferior vena cava through the lumbar vein (arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Cardiac penetration by cement embolus after percutaneous vertebroplasty. Although percutaneous vertebroplasty is a minimally invasive procedure, lethal complications, such as pulmonary embolism due to cement leakage, can occur. The incidence of pulmonary cement embolism has been reported to range from 2.1% to 26% after vertebroplasty.1Wang L.J. Yang H.L. Shi Y.X. et al.Pulmonary cement embolism associated with percutaneous vertebroplasty or kyphoplasty: a systematic review.Orthop Surg. 2012; 4: 182-189Crossref PubMed Scopus (95) Google Scholar Cement leakage into the inferior vena cava is a significant risk factor for developing pulmonary cement embolism.2Kim Y.J. Lee J.W. Park K.W. et al.Pulmonary cement embolism after percutaneous vertebroplasty in osteoporotic vertebral compression fractures: incidence, characteristics, and risk factors.Radiology. 2009; 251: 250-259Crossref PubMed Scopus (176) Google Scholar Cardiac embolism and even perforation can also occur in rare cases when cement emboli lodge in the right cardiac chambers.3D’Errico S. Niballi S. Bonuccelli D. Fatal cardiac perforation and pulmonary embolism of leaked cement after percutaneous vertebroplasty.J Forensic Leg Med. 2019; 63: 48-51Crossref PubMed Scopus (20) Google Scholar,4Zhang Y. Liu X. Liu H. Cardiac perforation caused by cement embolism after percutaneous vertebroplasty: a report of two cases.Orthop Surg. 2022; 14: 456-460Crossref Scopus (1) Google Scholar Urgent surgery is required for this condition.3D’Errico S. Niballi S. Bonuccelli D. Fatal cardiac perforation and pulmonary embolism of leaked cement after percutaneous vertebroplasty.J Forensic Leg Med. 2019; 63: 48-51Crossref PubMed Scopus (20) Google Scholar,4Zhang Y. Liu X. Liu H. Cardiac perforation caused by cement embolism after percutaneous vertebroplasty: a report of two cases.Orthop Surg. 2022; 14: 456-460Crossref Scopus (1) Google Scholar It is important to keep this life-threatening complication in mind for patients who have recently undergone percutaneous vertebroplasty. Point-of-care ultrasound may help in the diagnosis. This patient received an exploratory cardiotomy to remove intracardiac cement. She did well after surgery and was discharged 11 days later. https://www.annemergmed.com/cms/asset/c9d89a7e-bae9-45e5-9e2a-8758c4851526/mmc1.mp4Loading ... Download .mp4 (2.52 MB) Help with .mp4 files Video E1https://www.annemergmed.com/cms/asset/f090522a-4916-4c55-827a-db32f32e5b12/mmc2.mp4Loading ... Download .mp4 (1.14 MB) Help with .mp4 files Video E2