Veno-Arterial Extracorporeal Membrane Oxygenation with Conventional Anticoagulation Can Be a Best Solution for Shock Due to Massive PE

Abstract

SummaryWhile most of pulmonary thromboembolism (PE) cases can be managed by thrombolytic and anticoagulation therapy, massive PE remains a life-threatening disease. Although surgical embolectomy can be a curative therapy for massive PE, peri-operative mortality for hemodynamically collapsed PE is extremely high. We present a case of hemodynamically collapsed massive PE. We avoided either thrombolytic therapy or surgical embolectomy, because the patient had recent cerebral contusion. Therefore, we managed the patient with the combination of veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and conventional anticoagulation, which dramatically improved the patient's hemodynamics. In conclusion, the combination of V-A ECMO and conventional anticoagulation may be the preferred first line therapy for the patients with cardiogenic shock following massive PE.(Int Heart J 2017; 58: 831-834) Key words: Massive pulmonary embolism, Cardiogenic shock, Traumatic subarachnoid hemorrhage W hile most of pulmonary thromboembolism (PE) cases can be managed by thrombolytic and anticoagulation therapy, massive PE remains a life-threatening disease.1-3) Surgical embolectomy can be a curative therapy for massive PE.4) However, perioperative mortality for hemodynamically collapsed PE ranges from 43% to 84%.5) Therefore, when we encounter a hemodynamically collapsed massive PE, we have to make a difficult decision whether we should perform surgical embolectomy in a short time.Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) plays an important role in managing cardiogenic shock including massive PE. 6) In this case report, we present a case of hemodynamically collapsed massive PE. Surgical embolectomy seemed to be needed to recover from shock, but the surgical risk was extremely high because the patient had a recent cerebral contusion. V-A ECMO stabilized hemodynamics, and helped us to make a decision regarding treatment strategy. Case ReportA 55 year-old male patient with severe traumatic subarachnoid hemorrhage and hemorrhagic cerebral contusion was admitted to the intensive care unit (ICU) of our hospital. He had been immobilized in the ICU for 2 weeks. Although he put on a foot pump device to avoid deep vein thrombosis, he could not receive anticoagulation therapy because of the concerns of worsening brain hemorrhage. He started walking with parallel bars on day 28. At day 33, when he underwent rehabilitation program as usual, he suddenly fell down. His Glasgow coma scale was E4 V1 M5. His blood pressure (BP) and heart rate were 74/47 mmHg and 116/min, respectively. His respiratory rate was 30 breaths/min, and showed hypoxia (SpO2 75 %). An electrocardiogram (ECG) revealed sinus tachycardia, right axis deviation, and a right bundle branch block (Figure 1). Contrast enhanced computed tomography (CT) showed massive pulmonary thrombi in bilateral main trunks of the pulmonary artery (Figure 2A). We diagnosed him as massive PE. Then, he developed pulseless electrical activity following CT examination. We started car...

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