Assistant Professor, Anesthesiology n/a, United States
Introduction: Acute, massive pulmonary embolism (PE) is an embolus sufficiently obstructing pulmonary blood flow to cause right ventricular (RV) failure, hypoxemia, and hemodynamic instability.1 Extracorporeal membrane oxygenation (ECMO) is currently used as a rescue therapy for massive PE after cardiorespiratory arrest and not part of American Heart Association recommendations for management of massive PE, citing lack of evidence.2
Description: A previously healthy 48-year-old male presented from the airport in cardiogenic shock secondary to saddle PE with acute cor pulmonale and acute hypoxic respiratory failure. Massive burden of acute PE bilaterally with occlusive and partially occlusive thrombi involving bilateral main pulmonary arteries, with extension into all five lobar and multiple segmental and subsegmental branches, were identified on CTPE. Thrombus was present in the right ventricle on both computed tomography and echocardiography (TTE). TTE further revealed a dilated right ventricle with severely reduced systolic function. Initial Pulmonary Embolism Severity Index (PESI) score was 98 (intermediate-high risk). The patient had three episodes of cardiac arrest with return of spontaneous circulation. Initial management included thrombolytics, vasopressor and inotrope support and was deemed not a candidate for thrombectomy due to significant RV thrombus burden. Due to progressive hemodynamic instability, veno-arterial (VA) ECMO was initiated. The patient’s hospital course was complicated by acute renal failure requiring continuous renal replacement therapy, ischemic hepatopathy, and hemoperitoneum requiring blood transfusion. Ultimately, patient made a full recovery of all organ systems and was discharged home with outpatient therapy.
Discussion: The number of case reports are growing of the use of VA-ECMO for successful treatment of massive PE.3–5 With growing evidence of successful bedside and prehospital deployment of ECMO, early intervention of ECMO can be considered. Further research could investigate if intervention prior to cardiopulmonary arrest with ECMO cannulation could support improved outcomes in patients with massive saddle PE.
