SESSION TITLE: Critical Care Cases - Student/Resident
SESSION TYPE: Student/Resident Case Report Slide
PRESENTED ON: Sunday, October 25, 2015 at 10:45 AM - 11:45 AM
INTRODUCTION: In patients with massive pulmonary thromboembolism (PTE) and severe hemodynamic instability, tissue plasminogen activator (TPA) use immediately pre or post institution of veno arterial ECMO (VA ECMO) has been described.1,2,3 We report a case of full dose TPA successfully given to an adult patient 7 days post institution of VA ECMO for lysis of worsening PTE.
CASE PRESENTATION: A 46 year old female presented with acute hypoxemia due to PTE complicated by multiple pulmonary infarcts. PMH significant for BMI of 69, previous PTE, heparin induced thrombocytopenia (HIT) and IVC filter. Echocardiogram revealed low normal RV systolic function and argatroban was started. Shortly after she developed cardiogenic shock with SBP in 70s and severe hypoxemia, repeat echocardiogram showed worsening RV function. She was rapidly placed on VA ECMO via left femoral artery and right internal jugular vein and was continued on full dose argatroban. On day six a repeat chest CT scan showed worsening pulmonary infarcts, persistent PTE and TEE showed an akinetic RV. Due to the patient's continued dependence on VA ECMO for hemodynamic support and worsening function of RV, decision was made to perform fibrinolysis with 100 mg of TPA. After TPA infusion, she developed an upper gastrointestinal bleed requiring 8 u PRBC, and a large hematoma at the site of the femoral arterial cannula which required surgical management and multiple debridements. TEE on day 9 showed improved RV function and she was transitioned to VV ECMO. Day 14 VV ECMO was discontinued. She required tracheostomy, weaned from mechanical ventilation on day 37 and 7 weeks later discharged to home.
DISCUSSION: Treatment of massive PE consists of fibrinolysis or surgical embolectomy. There are few cases in the literature describing TPA given immediately prior to or post VA ECMO as adjunctive therapy.1,2,3 Our patient required VA ECMO for cardiovascular collapse, surgical embolectomy was felt too high risk due to HIT, large pulmonary infarctions and body habitus. We hoped she would improve with full anticoagulation; however, her right heart function deteriorated. After careful consideration of the significant risk of bleeding and discussion with the patient’s family, TPA was given with successful outcome.
CONCLUSIONS: To our knowledge this is the first report of fibrinolysis for worsening PTE given after a prolonged period on VA ECMO.
Reference #1: Chon, M., et al.(2014). Thrombolytic Therapy Complemented by ECMO: Successful Treatment for A Case of Massive Pulmonary Thromboembolism with Hemodynamic Collapse. Journal of Korean Medical Science,29, 735-738
Reference #2: Kurakazu, M., et al. (2012). Percutaneous cardiopulmonary support for pulmonary thromboembolism caused by large uterine leiomyomata. Taiwanese Journal of Obstetrics & Gynecology,51, 639-642.
Reference #3: Inoue, T., et al. (2002). Percutaneous cardiopulmonary support for the treatment of right ventricular thrombus. Perfusion,17, 73-75.
DISCLOSURE: The following authors have nothing to disclose: Ryan Rogers, Rita Pechulis, Philip Dunn, Matthew Miles
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