Can bone cement used in kyphoplasty (kyphoplasty) cause a myocardial infarction (heart attack)?

Bone Cement Embolism Following Kyphoplasty Can Cause Myocardial Infarction

Yes, bone cement used in kyphoplasty can cause myocardial infarction through cement embolization, which is a rare but well-documented and potentially life-threatening complication. This represents a Type 2 myocardial infarction, where a condition other than coronary artery disease contributes to an imbalance between myocardial oxygen supply and demand 1.

Mechanism of Cement Embolization

Cement leakage during kyphoplasty occurs in the following manner:

1. During the procedure, bone cement can leak into the paravertebral venous system
2. The cement can then travel through the venous circulation to the heart
3. Cement emboli can:
   • Cause direct mechanical obstruction of coronary arteries
   • Perforate cardiac chambers (particularly the right ventricle)
   • Lead to pericardial tamponade
   • Damage heart valves (particularly the tricuspid valve)

Evidence of Cardiac Complications from Kyphoplasty

Multiple case reports document this serious complication:

• Intracardiac cement embolism can lead to tricuspid valve regurgitation 2
• Cement can perforate the right ventricle, causing pericardial tamponade requiring emergency surgery 3
• Delayed cardiac perforation has been reported even 2.5 years after the initial procedure 4
• Patients may present with chest pain, chest tightness, and elevated myocardial enzymes after kyphoplasty 5

Diagnostic Considerations

When a patient develops chest pain following kyphoplasty:

• Standard fluoroscopy may miss cement emboli
• Chest CT and echocardiogram are the preferred diagnostic tools 5
• Elevated cardiac biomarkers may be present, indicating myocardial injury 1

Risk Factors and Prevention

To minimize the risk of cement embolization:

• Use cement with thicker consistency when filling multiple vertebral levels 4
• Carefully monitor for paravertebral intravascular leakage during the procedure
• Consider alternative materials like Cortoss (though this has also been associated with embolization) 6

Is This Malpractice?

The occurrence of cement embolization alone does not necessarily constitute malpractice. Cement leakage is a known complication of kyphoplasty, occurring in approximately 10-15% of cases 4. However, several factors would need to be considered:

1. Whether appropriate patient selection criteria were followed
2. Whether proper technique was employed during the procedure
3. Whether the patient was adequately informed of this potential risk
4. Whether appropriate monitoring and follow-up were conducted

Management of Cement Embolization

When cement embolization to the heart is detected:

• Immediate cardiac evaluation is essential
• Echocardiography to assess for pericardial effusion, valve damage, and chamber perforation
• Emergency cardiac surgery may be required to remove cement fragments and repair damage 6, 3
• Long-term follow-up is necessary as complications can develop months or even years after the procedure 4

Key Takeaways

1. Cement embolization is a rare but potentially fatal complication of kyphoplasty
2. It can cause Type 2 myocardial infarction through various mechanisms
3. Patients with post-kyphoplasty chest pain should undergo thorough cardiac evaluation including CT and echocardiography
4. Early recognition and intervention are crucial for preventing serious outcomes

This case highlights the importance of vigilance following vertebral augmentation procedures and maintaining a high index of suspicion for cardiac complications when patients develop chest symptoms.