The Utility of Mechanical Circulatory Support in the Management of Massive Pulmonary Embolism with Right Ventricular Failure
Sunita K Mahabir, MBBS, Allegheny General Hospital, Pittsburgh, PA
Sunita K Mahabir, MBBS, Nazli K Okumus, MD and Adnan Khalif, M.D., FSCAI, Allegheny General Hospital, Pittsburgh, PA
Title
The Utility of Mechanical Circulatory Support in the Management of Massive Pulmonary Embolism with Right Ventricular Failure Introduction
Right ventricular failure (RVF) is a significant cause of morbidity and mortality. Massive pulmonary emobolism is often complicated by acute RVF. Our case demonstrates the successful management of RVF using mechanical circulatory support (MCS) devices in adjunct with surgical interventions.
Clinical Case
Patient is a 47-year-old obese male who presented with sudden onset shortness of breath, decreased exercise tolerance and was found to be COVID-19 positive. His past medical history was significant for hyperlipidemia, uncontrolled diabetes and hypothyroidism. The patient was found to have a large saddle embolus with extension into the right and left main pulmonary arteries with evidence of right heart strain on CT. His echocardiogram showed a preserved ejection fraction but severely dilated right ventricle (RV) (RVIDd 5 cm) with severely depressed systolic function of the RV with McConnell's sign. He was hypoxic and hypotensive with an elevated lactic acid at the time of presentation so he was placed on VA ECMO and underwent percutaneous catheter directed mechanical thrombectomy. Patient was then placed on milrinone and was on 8 litres of oxygen via nasal canula. Pulmonary artery pressure was 64/21 mmHg post procedure. When weaning of ECMO was attempted, his RV was noted to be severely dilated and dysfunctional. Repeat CT showed persistence of the saddle embolus with extensive bilateral occlusive emboli with multi-lobar extension. The decision was then made to undergo surgical pulmonary endarterectomy to give a better chance at RV recovery. The patient was kept on ECMO post procedure and was able to tolerate ECMO weaning and decannulation one day later. He was also started on inhaled nitric oxide. Unfortunately, soon after he developed an elevated lactic acid, his CVP was 13-14 mmHg and he became hypotensive needing increasing pressor support all suggestive of recurrent RV failure. A Protek Duo with oygenator was then placed which allowed the inhaled nitric oxide, milrinone and dopamine to be weaned gradually over the next week. The patient was able to be taken off all mechanical support and a repeat echocardiogram showed marked improvement in the RV function with no residual McConnell’s sign. He was discharged from the hospital one week after device removal to inpatient rehabilitation. Management decisions were made jointly by the Interventional Cardiology, Cardiothoracic Surgical, Heart Failure and Critical Care Medicine teams throughout the course of his stay.
Discussion
Right ventricular failure has historically been associated with poor prognosis. This case illustrates how the early recognition of RVF, timely implementation of implantable MCS devices and multi-disciplinary shock team approach were able to successfully support a patient to recovery from acute RVF secondary to massive pulmonary embolism. Routine use of MCS devices in conjunction with surgical interventions can help optimize outcomes in this patient population.