VENO-ARTERIAL ECMO AS A BRIDGE TO EMERGENT PULMONARY THROMBECTOMY IN A PATIENT WITH CARDIOPULMONARY ARREST

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Massive pulmonary embolism (PE) is associated with a high mortality. Systemic anticoagulation, systemic thrombolytics, and direct surgical thrombectomy are standard therapeutic options. Use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in patients with a massive PE has been retrospectively associated with an improvement in mortality. We report the case of a trauma patient who survived intraoperative cardiopulmonary arrest secondary to a massive saddle PE after being placed on VA-ECMO as a bridge to emergent pulmonary thrombectomy. CASE PRESENTATION: A 31-year-old female presented to our hospital after a motor vehicle accident that resulted in a left femoral head fracture and dislocation, right fibular fracture, a small right temporal subarachnoid hemorrhage, and a left temporal laceration. On the day after admission during the orthopedic surgery, the patient was noted to have significant oxygen desaturation. The patient quickly developed cardiac arrest requiring multiple rounds of CPR. Bedside transthoracic echocardiography identified right ventricular strain with sonographic McConnell sign. While actively undergoing CPR, the patient was emergently placed on ECPR with VA-ECMO. Subsequent CT angiography revealed a massive saddle pulmonary embolism with extensive right and left pulmonary artery involvement. The patient was taken for surgical pulmonary artery thrombectomy with successful removal of large clot burden from the right and left pulmonary arteries, allowing almost immediate post-operative discontinuation of VA-ECMO and vasopressor support. The patient required inotropic support for acute right heart failure that was successfully weaned in the following week. The patient’s hospital course was complicated by rhabdomyolysis and compartment syndrome requiring fasciotomy. She discharged with oral anticoagulation, intact neurologic function, and the ability to ambulate without oxygen. DISCUSSION: A recent descriptive study found that ECMO is being used more often for patients with high-risk PE (0.07% to 1.1%). A retrospective case-control study of 56 patients found a significant improvement in survival for patients with massive PE that were placed on VA-ECMO as a bridge to further intervention compared to a control group (96% vs. 73%). While ECPR is recommended as part of the 2015 American Heart Association ACLS guidelines, this case provides a successful example of ECPR and VA-ECMO that allowed time for definitive management of a reversible cause. CONCLUSIONS: In patients with a massive PE who experience cardiopulmonary arrest, ECPR and VA-ECMO should be considered as an option to bridge the patient to a definitive surgical option. Reference #1: Elbadawi A et al. National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism. Vasc Med. 2019 Mar 5:1358863X18824650. https://doi.org/10.1177/1358863X18824650. Reference #2: Pasrija C et al. Triage and optimization: A new paradigm shift in the treatment of massive pulmonary embolism. DISCLOSURES: No relevant relationships by Rohini Chatterjee, source=Web Response No relevant relationships by John Hunninghake, source=Web Response No relevant relationships by Thomas Lee, source=Web Response Speaker/Speaker's Bureau relationship with Jansseen Pharmaceuticals Please note: $5001 - $20000 Added 11/19/2018 by Michael Morris, source=Web Response, value=Salary No relevant relationships by Matthew Read, source=Web Response No relevant relationships by Michal Sobieszczyk, source=Web Response No relevant relationships by Preston Sparks, source=Web Response