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Cardiac and pulmonary cement embolism after vertebroplasty – an uncommon cause of valvular mass
Session:
Prémio Melhor Caso Clínico
Speaker:
Pedro Miguel Mangas Neto da Palma
Congress:
CPC 2026
Topic:
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Theme:
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Session Type:
Sessão de Prémios
FP Number:
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Authors:
Pedro Mangas Palma; Ana Isabel Pinho; Helena Moreira; Miguel Rocha; Carla Sousa; Marta Braga; Mariana Vasconcelos
Abstract
<p style="text-align:justify"><strong>Patient presentation</strong></p> <p style="text-align:justify">A 45-year-old male patient was referred for evaluation prior to autologous hematopoietic stem cell transplantation (aHSCT). The patient reported no symptoms and underwent a complete physical examination, which revealed no abnormal findings. An initial ECG showed normal sinus rhythm with non-specific repolarization changes. During a routine TTE, an unexpected echodense mass was identified, entangled in the tricuspid subvalvular apparatus and associated with mild tricuspid regurgitation. To further characterize the mass, a TOE was performed, revealing a hyperechoic bilobed mass measuring up to 15 × 5 mm, with a mobile extremity on the ventricular aspect demonstrating a whip-like movement. Given the patient’s asymptomatic status, a conservative approach was adopted, with a plan for close monitoring and follow-up.</p> <p style="text-align:justify">The patient’s past medical history included a NSTEMI, managed with percutaneous angioplasty of the circumflex artery with a stent. Additionally, the patient had an established diagnosis of IgG lambda multiple myeloma, associated with extensive lumbar osteolytic bone disease, which led to percutaneous vertebroplasty. Management included induction therapy, followed by aHSCT. Three weeks after the initial evaluation, after aHSCT, the patient’s condition deteriorated significantly, as he presented with fever of unknown origin.</p> <p style="text-align:justify"><strong>Initial work up</strong></p> <p style="text-align:justify">Differential diagnoses included vegetations, degenerative calcification, cardiac tumors and embolism. Additionally, in a patient with a new right heart mass and history of vertebroplasty, cement cardiac embolization must be considered. Repeat transthoracic echocardiography showed no changes. A PET scan demonstrated no increased cardiac metabolic activity, making infective endocarditis unlikely.</p> <p style="text-align:justify"><strong>Diagnosis and management</strong></p> <p style="text-align:justify">Cardiac CT revealed multiple high-density linear structures within pulmonary arterial branches and dense branched material adherent to the tricuspid subvalvular apparatus and chordae tendineae, consistent with cement embolization, without associated thrombus. Following multidisciplinary Heart Team discussion, conservative management was chosen due to the patient’s asymptomatic status, preserved valvular function, low risk of cardiac perforation, and high surgical risk. Neutropenic fever resolved after antibiotic therapy.</p> <p style="text-align:justify"><strong>Follow-up</strong></p> <p style="text-align:justify">The patient remains clinically stable. Serial TTE shows a stable tricuspid subvalvular mass with mild tricuspid regurgitation.</p> <p style="text-align:justify"><strong>Conclusions</strong></p> <p style="text-align:justify">Cement embolization is a rare but serious complication of vertebroplasty, with variable presentation and potentially severe cardiac consequences. Diagnosis often requires advanced imaging, and management must be tailored to embolus features and patient condition.</p>
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