Cardiac Emboli Documented by Intra-Operative Trans-Esophageal Echocardiogram (TEE) During Administration of a Topical Hemostatic Agent Prior to Pedicle Subtraction Osteotomy (PSO).

STUDY DESIGN Outcomes measurement OBJECTIVE: Describe the occurrence of cardiac emboli recorded on trans-esophageal echocardiogram (TEE) after the injection of a topical hemostatic agent into a vertebra prior to performing a pedicle subtraction osteotomy (PSO). SUMMARY OF BACKGROUND DATA Hemostasis during spinal surgery is critical for adequate visualization and to reduce the risk of peri-operative complications. Adult spinal deformity (ASD) surgery can involve performing PSOs which are useful in cases of fixed spinal deformities and are associated with increased blood loss secondary to epidural and cancellous bleeding. Prior to performing a PSO, a topical hemostatic agent can be injected into the vertebra through the pedicle screw pilot holes in an attempt to decrease cancellous bleeding. Injected hemostatic agents can pressurize the vertebral body similar to cementation in vertebroplasty and during fracture reaming and prosthetic implantation in the femur. Patients with cardiac defects such as patent foramen ovale or atrial septal defect may be more prone to systemic embolic events resulting in morbidity or mortality. METHODS We injected a topical hemostatic matrix agent through the pedicle screw pilot holes into the L1 vertebral body prior to performing a PSO while simultaneously recording with TEE. RESULTS The TEE recorded large visible emboli traveling through the heart into the pulmonary vasculature. The patient remained stable throughout the remainder of the case and a post-operative spiral CT scan was negative for filling defects. The patient had an uneventful hospital course. CONCLUSIONS Questions remain about the exact consistency of these emboli, when they are most likely to occur, how much cardiopulmonary insult can be tolerated without resulting in complications, or how to prevent their occurrence. Patients undergoing spinal surgery with the plan to inject hemostatic matrix agents into the vertebral body may benefit from a pre-operative TEE to reduce the risk of complications associated with embolic events, especially in patients with undiagnosed patent foramen ovale or atrial septal defect. LEVEL OF EVIDENCE 2.