Simultaneous Use Of Mechanical Circulatory Support And Catheter-Directed Thrombolysis For Massive Pulmonary Embolism
Journal of the American College of Cardiology
Background: Right ventricular failure (RV) secondary to massive pulmonary embolism (PE) is associated with high morbidity and mortality. The Impella RP mechanical circulatory support (MCS) device has been approved for RV support for patients who develop acute right heart failure following left ventricular assist device implantation, myocardial infraction, heart transplant or open-heart surgery. We report a case with massive PE and acute RV failure, in which early use of combination Impella RP and ultrasound-associated catheter-directed thrombolysis (USACDT) lead to resolution of shock and multi-organ failure (MOF). Case: A 57-year-old lady presents with acute dyspnea. She was hemodynamically unstable and cardiac biomarkers were markedly elevated. A computed tomogram showed extensive bilateral PE with evidence of right heart strain with positive McConnell’s sign on echocardiogram. She was intubated and developed refractory shock. She underwent USACDT. Despite therapy, she remained on high doses of multiple vasopressors and developed worsening MOF. She was taken emergently for cardiac catheterization and an Impella RP was placed into the left PA, without interruption of USACDT. Severe pulmonary hypertension and right heart failure were confirmed. With the device in place, the patient became more hemodynamically stable. She had complete resolution of MOF and RV failure. Decision-making: Although Impella RP use for PE is off-label, the principle of off-loading the RV is the same. In cases of refractory shock despite medical and USACDT therapy, short-term MCS is reasonable to provide hemodynamic support and facilitate RV recovery. The device also lessens the need for vasoactive medications and their harmful coronary and peripheral vasoconstrictive effects and has easier deployment and smaller access site in comparison to ECMO. Conclusion: A combination of early USACDT and percutaneous MCS, in addition to medical therapy, may lead to improvement in morbidity and mortality for massive PE. Further studies need to be performed in order to better establish the safety and efficacy of combination USACDT and MCS as the combination shows promise in the management of massive PE.
9 Supplement 1
Assar S, Haydar H, Chattahi J. Simultaneous use of mechanical circulatory support and catheter-directed thrombolysis for massive pulmonary embolism. J Am Coll Cardiol 2019 March: 73(9 Supp 1): 2836.