Intracardiac Cement Embolism

A 78-year-old woman was presented with sharp chest pain and dyspnea as a chief complaint in the midst of hemodialytic session.Just 2 days before her visit to emergency department, she received vertebroplasty for L1 to L3 osteoporotic compression fracture.The patient has a medical history of endstage renal disease, type 2 diabetes, hypertension, tongue cancer, and bladder cancer.The physical examination was normal, and the vital signs taken initially revealed elevated blood pressure but absence of tachycardia (blood pressure 176/75 mm Hg, heart rate 67 bpm).Blood tests showed elevated levels of cardiac markers and D-dimer (troponin-T, 107.8 ng/L [normal range <14], NT-proBNP [N-terminal pro-B-type natriuretic peptide], 9348 pg/mL [normal range <1800 for risk of heart failure], D-dimer, 2.79 mg/L [normal range <0.549]).ECG exhibited normal sinus rhythm without significant ST-segment deviation.Chest radiography exposed 2 needle-like fragments in the middle of her mediastinum shadow (Figure [A]).The patient was discharged from the hospital on the same day, as symptoms ameliorated under antianginal agents.At our cardiology clinic, transthoracic echocardiography unveiled one highly echogenic and slender structure in right atrium and right ventricle, traversing the tricuspid annulus.Left ventricular systolic function and chamber size remained normal with no disruption of tricuspid valve.Small amount of pericardial effusion was present without obvious diastolic collapse of right ventricle (Figure [B and C], Movie I in the Data Supplement).Computer tomography study showed 2 high-attenuation emboli in the right heart and right pulmonary artery respectively (maximal 583 Hounsfield units; Figure [D and E]), measuring up to 8 cm.There was a small amount of pericardial effusion, possibly due to ventricular penetration or pericarditis.Intravascular foreign bodies with similar characteristics also resided in intervertebral veins, with extension into azygos vein and inferior vena cava (Figure [F]).Intracardiac emboli were thus believed to be as a result of bone cement leakage.The patient remained under reasonable carrying out before hospitalization.Fierce chest pain subsided, yet chest tightness upon deep inspiration still bothered her.Retrieval was indicated due to symptomatic intracardiac embolism.Endovascular approach was attempted after discussion based on our cardiovascular team.Cement drainage into intervertebral veins could be clearly observed under fluoroscopy.Two slender cement remnants were identified.We tried to retrieve with handcrafted loop snares using 8 French Judkins right catheter, 0.035-inch glidewire and 0.018-inch V-18 guidewire.Retrieval was not successful despite successful snaring of both remnants.The one in pulmonary artery was tugged back into right ventricle, but soon cracked in halves, ended up back in distal pulmonary artery branches.We dragged the other in the right heart chamber to right iliac vein but still failed to retrieve into 8 French venous sheath (Movie II in the Data Supplement).Postprocedural echocardiography showed stationary Intracardiac Cement Embolism