1264: EXTRACORPOREAL MEMBRANE OXYGENATION IN MASSIVE PULMONARY EMBOLISM: THE CHALLENGES OF DIAGNOSIS OF PE

Abstract

Introduction: Pulmonary embolism (PE) is the third most common cause of death after myocardial infarction & stroke. Diagnosis is challenging without a computed tomographic pulmonary angiography (CTPA), & advanced management techniques are difficult to implement without confirmation. We present a patient who was unable to undergo a CTPA, but through a multidisciplinary approach was progressed to veno-arterial extracorporeal membrane oxygenation (VA ECMO). Description: A 245-kg 30-year-old male was admitted for Ludwig’s angina, fiber-optically intubated, taken for incision & drainage, & later successfully extubated. Two days later, he became increasingly hypoxic, leading to reintubation and initiation of a heparin infusion for suspected massive PE. Point of care ultrasound was non-diagnostic due to poor acoustic windows & CTPA unobtainable due to the patient’s body habitus. He progressed to obstructive shock & refractory hypoxia. Lower extremity (LE) dopplers were positive for extensive deep venous thrombosis. A multidisciplinary team including critical care, interventional cardiology & cardiothoracic surgery, opted to proceed to the catheterization lab for a transesophageal echocardiogram (TEE) & pulmonary angiography for diagnosis & attempted thrombectomy with VA ECMO as backup. TEE showed a severely dilated right ventricle (RV) with strain. Angiography confirmed extensive PE, but catheter advancement induced ventricular fibrillation & thrombectomy was aborted. Patient was then cannulated for VA ECMO. Discussion: CTPA is the first line diagnostic technique in patients with PE. Unfortunately, our patient’s body habitus limited the ability for this modality. Catheter pulmonary angiography has been considered too invasive solely for diagnosis but has been favored over CTPA when endo-vascular intervention is intended. Angiography has its limitations, including ease of availability, risk of hemodynamic compromise in severe RV failure & interpretation of imaging. Although this is a concern, it should not deter from making a diagnosis given the case-fatality of an undiagnosed PE. We aim to recognize the challenges in PE diagnosis and to reiterate the importance of a multidisciplinary approach in massive PE to broaden therapeutic options and improve mortality.