PV has become increasingly common for the treatment of vertebral compression fractures in the last three decades [1 ~ 3]. Pulmonary bone cement embolisms during PV procedures have been extensively reported. Their incidence ranges from 2.1 to 26%; most of them are asymptomatic and have no clinical consequence༻2 ~ 4༽. Even though all pulmonary cement embolisms first pass through the heart cavities, some cement fragments may stay inside the heart. ICE have been poorly reported in the literature. Opinions also differ regarding whether the clinical consequences of this specific complication of PV is benign or malignant. The incidence of ICE during PV is low (3.9%)༻4༽, and most patients with ICEs (93%) are asymptomatic. However, in a systematic review of the literature, Hatzantonis et al ༻5༽found that ICE-related clinical manifestations vary from asymptomatic (5.5%) and mild symptoms, such as chest pain, syncope, or moderate dyspnea (72%), to life-threatening conditions, such as acute respiratory distress or cardiac tamponade (22.2%). In our case, the patient was initially misdiagnosed as simple pneumothorax because we overlooked the radio-plaque opacity located only in the RA. Our patient presented with signs and symptoms of recurrent pneumothorax and pericarditis caused by the migrated and protruding RA fragment after the first right pneumothorax 5 months earlier. We think that a simultaneous RA and lung perforation occurred when the hardened cement fragment in the RA, anchored to the tricuspid valve annulus, was fractured and pushed upward through the pericardium and pleura due to pericardial adhesion during cardiac systole.
To date, no consensus exists in the literature regarding the best management of ICE. The choice of treatment for ICE depends on the location of the cement and the symptom severity. Current treatment options are conservative management with symptomatic treatment, oral anticoagulation for 3 to 6 months until the bone cement endothelializes and stops being thrombogenic, percutaneous retrieval (especially for RA leakage), or open-heart surgery [4, 5]. In our review of the literature, severe symptomatic patients tended to have more ICEs in the right ventricle and multiple fragments were more frequently detected. In addition, more patients have undergone open cardiac surgery or percutaneous retrieval than there have been asymptomatic patients༻3 ~ 5༽. Our patient had a similar tendency except the localization in the RA.
To the best of our knowledge, this report is the first to describe simultaneous cardiac and lung perforation by bone cement in the RA after PV. In addition, this case has the longest interval (1 year after PV) for surgical treatment.
In conclusion, ICE-related cardiorespiratory complications may be delayed and surgical retrieval must be considered to prevent progression to chronic constrictive pericarditis in symptomatic ICE.