Spinal cord tissue has a remarkable resistance to infection. An intramedullary abscess is an exceptional complication of infective endocarditis in the post-antibiotic era. We describe the case of a 42-year-old man who presented with fever and cephalea. Two days later, left-side numbness, lack of sphincter control, and a new aortic murmur were noticed. Magnetic resonance imaging demonstrated an 8 ×15-mm intramedullary cervical abscess. Transesophageal echocardiography revealed an aortic valve perforation as a result of infective endocarditis. Conservative management was decided for the intramedullary abscess.
A 71-year-old woman was admitted to hospital after a car crash and diagnosed with L1 vertebral body fracture. A percutaneous transpedicular lumbar fixation using polymethylmethacrylate (PMMA) cement was decided. During the procedure, a massive PMMA cement leakage into the paravertebral venous system was observed. Hypotension, acute respiratory distress and refractory hypoxaemia were rapidly manifested. A cement pulmonary embolism was suspected and an unenhanced CT performed. A large collection of PMMA fragments were distinguished in the right pulmonary artery (RPA) and lobar branches ( figure 1A). A huge PMMA piece was seen inside the RV (figure 1B) and identified on chest radiography (figure 1C). Because of the critical condition of the patient and the size of the cement pieces, surgical management was decided. During anaesthesia induction, hypotension and ventricular tachycardia appeared. Cardiopulmonary bypass was immediately established. Through the right atriotomy, the RV was explored without findings. Afterwards, an RPA arteriotomy revealed elongated PMMA fragments in the right pulmonary branches ( figure 1D). A main pulmonary trunk arteriotomy showed a huge PMMA piece entrapped in the main pulmonary bifurcation ( figure 1E). A large collection of cement fragments were successfully removed ( figure 1F). The larger piece resembled the big one detected inside the RV on CT and chest radiography, probably embolised during induction of anaesthesia and responsible for the final acute hemodynamic instability. Postoperatively, the patient recovered uneventfully.PMMA cement pulmonary artery embolism is a rare complication after percutaneous vertebroplasty. Frequently underreported, clinical manifestations are variable, from asymptomatic to respiratory distress or death. Treatment is controversial. The current trend consists of conservative management. Pulmonary embolectomy is exceptional and usually associated with high mortality. Figure 1 (A) Unenhanced CT shows several hyperdense intraluminal opacities into the distal right pulmonary artery (RPA) and lobar branches (arrow). (B) CT scan reveals a hyperdense material inside the RV consistent with cement embolism. (C) Chest radiograph confirming presence of a big cement piece inside the RV. (D) Extraction of filamentous fragments of polymethylmethacrylate (PMMA) from the RPA. (E) Removal of the big PMMA cement piece through the main pulmonary trunk arteriotomy, consistent with the big piece observed preoperatively inside the RV on CT scan and chest radiograph. (F) All PMMA fragments removed during surgery.
Mortality in our population was higher than the mortality that would have been expected by the new EuroSCORE II analysis. Although EuroSCORE II has good calibration and discrimination capacity, both are worse than those demonstrated by logistic EuroSCORE. Forthcoming evaluations are necessary when the new model will be widely used.
A patient who underwent previous implantation of a mitral valve replacement with a Björk-Shiley Delrin (BSD) mitral valve prosthesis during infancy was admitted to our institution 43 years later after an episode of syncope and cardiac arrest. Under extreme hemodynamic instability, a mitral valve prosthetic dysfunction causing massive mitral regurgitation was identified. The patient underwent an emergent cardiac operation, and a complete disc fracture with partial disc migration was found. Exceptional cases of mechanical prosthetic heart valve fracture exist. We report the first case of complete transversal disc rupture of a BSD mitral valve prosthesis after the longest period of implantation ever reported in that position.
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