SESSION TITLE: Cardiovascular Cases I
SESSION TYPE: Medical Student / Resident Case Report
PRESENTED ON: Sunday, October 27, 2013 at 07:30 AM - 08:30 AM
INTRODUCTION: A massive PE is defined as more than 50% obstruction of the pulmonary artery resulting in significant hemodynamic compromise from right ventricular overload. While systemic anti-coagulation has been shown to reduce mortality and is considered first-line therapy, thrombolytic therapy accelerates the breakdown of an acute embolism and can dramatically improve hemodynamics. We report a case of intraoperative PE that is successfully treated with emergent extracorporeal membrane oxygenation and tPA delivered directly through a pulmonary artery catheter.
CASE PRESENTATION: 44 year-old obese female with history of uncontrolled diabetes presented with necrotizing fasciitis of the abdominal wall. She had undergone multiple uncomplicated wound debridements and her hospitalization was otherwise unremarkable. On hospital day 15, the patient underwent a repeat debridement of her abdominal wound under general anesthesia. Heparin was held for 24 hours pre-operatively. Midway through the case, the patient became increasingly hypoxic (82%), tachycardic with a decreased end-tidal carbon dioxide (15 mmHg). An acute pulmonary embolism was suspected. Transesophageal echocardiography exhibited an obstructive thrombus in the right pulmonary artery, a hyperdynamic, underfilled LV, and dilated right ventricle. Epinephrine and vasopressin infusions were started along with inhaled nitric oxide. The patient progressed to right ventricular failure and cardiogenic shock. The patient was emergently placed on venoarterial ECMO. In the ICU, a tPA infusion was started via PA catheter for directed thrombolysis. A total of 40mg was given over four hours, followed by a heparin infusion, which resulted in a significant improvement in hemodynamic. There were no major bleeding complications. The following day, the TEE showed significant resolution of the right PA thrombus, normal sized right-sided chambers as well as normal biventricular function. ECMO was successfully removed and the patient remained hemodynamically stable.
DISCUSSION: Thrombolytic therapy should be considered when there is acute hemodynamic compromise. Several studies have shown benefit with central or peripherally administered thrombolytic therapy when compared to heparin alone. Thrombolytics are associated with a higher risk of severe bleeding, but no study to date has addressed the issue of mortality benefit although there seems to be a clear clinical benefit over anticoagulation alone.
CONCLUSIONS: Acute intraoperative pulmonary embolism can result in hemodynamic compromise, but can have a good prognosis if diagnosed early and aggressive supportive management is initiated.
Reference #1: Amirghofran, A.A., Emami Nia, A., Javan, R. Surgical Embolectomy in Acute Massive Pulmonary Embolism. Asian Cardiovasc Thorac Ann 2007;15:149-153
Reference #2: Chauhan TA and More RS. Pulmonary embolism - an update on thrombolytic therapy. QJMed 2000;93:261-267
Reference #3: Agnelli, G. Prevention of venous thromboembolism. Circulation 2004; 110:4-12
DISCLOSURE: The following authors have nothing to disclose: Ricky Harika, Cynthia Wells
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