Novel Approach to Manage Cardiogenic Shock due to Simultaneous Right Atrial and Saddle Pulmonary Embolus
Presenter
Muhammad Ajmal, MD, University of Arizona Medical Center, Tucson , AZ
Muhammad Ajmal, MD1, Sulaiman Aziz Rathore, M.D.2, Zain Khalpey, MD3 and Dexter Deleon, MD2, (1)University of Arizona Medical Center, Tucson , AZ, (2)Northwest Allied Physicians, Tucson, AZ, (3)Holyoke Medical Center, Holyoke, MA
Keywords: Cardiogenic shock and Pulmonary Embolism (PE)
Background:
The prognosis of pulmonary embolism is based on the hemodynamic status of the patient. The best percutaneous approach to manage massive pulmonary embolism when it's associated with right atrial thrombus in transit is unknown.
Methods:
N/A
Results:
A 74-year-old male with past medical history significant for ischemic cardiomyopathy with an ejection fraction of 25-30% and known left ventricular (LV) thrombus presented to the emergency department with sudden onset of shortness of breath and diagnosed with saddle PE and RA thrombus in transit.On examination, he was found to be hypotensive with a mean arterial pressure of 57 mmHg and hypoxic with oxygen saturation of 84%. The patient also had a history of essential hypertension (HTN), remote ischemic stroke, coronary artery disease status post coronary artery bypass graft 16 years ago, and had ICD for the primary prevention of sudden cardiac death. Electrocardiogram, complete blood count and complete metabolic panel, high sensitivity troponin, and pro-BNP were normal. His presentation was consistent with cardiogenic due to massive PE and management was complicated due to his comorbid conditions. The patient was at high risk for surgical embolectomy and with systemic fibrinolysis, there was a risk for further embolization of RA and LV thrombus and the most feasible approach considered was the percutaneous approach after the heart team approach. Because of the simultaneous presence of RA thrombus and saddle PE, a single approach of thrombectomy or fibrinolysis was not sufficient and a hybrid novel approach to extract the thrombus from the right atrium using AngioVac and to extract thrombus from pulmonary arteries using FlowTriever (Inari Medical) with VVA ECMO using an extra reservoir in the circuit for AngioVac was the most suitable approach. After removing RA and PA clots, the ECMO was weaned down with stable hemodynamics and the patient was transferred to the cardiovascular intensive care unit in stable condition and was discharged on day 3 without the need for oxygen.
Conclusions:
The hybrid approach of thrombectomy of saddle embolus with Flow Triever and AngioVac of RA thrombus in transit utilizing VVA ECMO support is a reasonable approach to manage massive PE with RA thrombus in transit.