Use of low-dose thrombolytics for treatment of intracardiac thrombus and massive pulmonary embolus after aborted liver transplant leads to recovery of right ventricular function and redo liver transplantation

Abstract

This is a 61-year-old man with end-stage liver disease who experienced cardiac arrest secondary to a massive pulmonary embolus and intracardiac thrombus during cannulation for veno-venous extracorporeal membrane oxygenation (ECMO) in preparation for orthotopic liver transplantation (OLT). Surgery was aborted and the patient was taken back to the intensive care unit in cardiogenic shock on multiple vasopressors. The patient was unresponsive to heparin bolus and too high risk for systemic thrombolytics or embolectomy. He was ultimately treated with 12 mg total of alteplase through his pulmonary artery catheter over 3 hours. He had subsequent resolution of his cardiogenic shock and proceeded with successful liver transplantation 5 days after his initial event without any bleeding complications. Low-dose thrombolytic therapy in the setting of absolute contraindications to thrombolysis allowed for recovery of cardiac function and, ultimately redo OLT in a patient with otherwise little hope of survival.

Clinical Pearls of Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock

“…Moreover, if we consider the ECMO's physiology of partial cardiopulmonary bypass, VA ECMO is the most suitable device for the pathophysiology of right heart failure from PTE. After the patient becomes stable, the treatment for the thrombus should be selected among the following options: anticoagulation,25)29) systemic thrombolysis,30) catheter-directed thrombectomy or thrombolysis,31) or surgical embolectomy 24)26). The European Society of Cardiology 2014 acute PTE guidelines briefly mention that ECMO can be used to treat massive PTE as a method for hemodynamic support and as an adjunct to surgical thrombectomy 32).…”

Intraoperative circulatory arrest secondary to high-risk pulmonary embolism. Case series and updated literature review.

“…Doses of 0.6 mg/kg of tPA have demonstrated effectiveness in preventing mortality in high-risk PE [33,34]. Furthermore, a case of PE associated with CA in a patient with cirrhosis and thrombocytopenia (high risk of bleeding) was reported, in which a total dose of 12 mg of tPA was administered, resulting in symptomatic improvement and no evidence of residual thrombus on follow-up ETT [35]. Similarly, doses up to 2 mg of tPA have been reported with satisfactory results [34].…”