INTRODUCTION: Pulmonary embolectomy is highly effective on hemodynamically unstable patients with massive pulmonary embolism.. We present a case of massive pulmonary embolism associated with cardiac arrest who was successfully treated with pulmonary embolectomy.
CASE PRESENTATION: A 21-year-old college student presented to the emergency department after a syncopal episode. He complained of chest pain and shortness of breath. A chest computed tomography scan showed massive bilateral pulmonary artery emboli(figure 1). Thrombolytics were administered and shortly thereafter he suffered cardiopulmonary arrest. The patient was taken emergently to the operating room while undergoing cardiopulmonary resuscitation. The patient was placed on cardiopulmonary bypass while receiving chest compressions. Pulmonary embolectomy was performed through incisions on the right and left pulmonary arteries. There were 2 large fully occlusive clots in the right and left main pulmonary arteries (figure 2). Valsalva maneuvers and direct compression of the lungs were performed to aid in extracting distal pulmonary clots. After the embolectomy, the heart resumed sinus rhythm. There was moderate right ventricle dysfunction that required milrinone and nitric oxide support. An inferior vena caval filter was placed prior to his return to the ICU. The patient woke up and had no neurological deficit. He was extubated the following day. He had bilateral lower extremity duplex with a small thrombus noted in his left saphenous vein. No hypercoagulable state was identified. The patient was fully anticoagulated and discharged home on post operative day #8. Figure 1: CT PULMONARY ANGIOGRAM shows large central pulmonary embolism with occlusion of both right and left pulmonary arteries. Figure 2: Emboli removed from this patient.
DISCUSSIONS: Massive pulmonary embolism is associated with cardiopulmonary collapse . The mortality for patients who present on cardiac arrest is at least 67%. Cardiac arrest is not only a marker of hemodynamic severity and poor prognosis of the embolism but it also is associated with high risk of neurological injury.
CONCLUSION: This case shows that an aggressive approach on selected patients with massive pulmonary embolism and cardiac arrest may be justified. Pulmonary embolectomy in patient with cardiac arrest should be consider in young patients, with limited comorbidities, and with short periods of cardiopulmonary resuscitation. Adherence to those criteria will improve outcomes and allow for complete chance of neurologic recovery. If the likelihood of neurological recovery is high, mechanical circulatory support for a failing right ventricle should be considered.
DISCLOSURE: Paul Vesco, No Financial Disclosure Information; No Product/Research Disclosure Information