Ultrasound-accelerated thrombolysis and extracorporeal membrane oxygenation in a patient with massive pulmonary embolism and cardiac arrest.

A 72-year-old man presented to the emergency department in cardiogenic shock; 4-days before he was diagnosed with right femoro-popliteal deep vein thrombosis after trauma. During routine monitoring and diagnostic workup, cardiac arrest with pulseless electric activity rapidly ensued and cardiopulmonary resuscitation was initiated. A transtho-racic echocardiogram showed severe right ventricular dilata-tion and acute pulmonary embolism was suspected. No Return of Spontaneous Circulation was obtained after 10 minutes of cardiopulmonary resuscitation. The patient was transferred to the cardiac catheterization laboratory under resuscitation with autopulse (ZOLL, Chelmsford, MA) and femoro-femoral veno-arterial extracorporeal membrane oxygenation (ECMO; PLS Maquet GmbH, Rastett, Germany) was percutaneously initiated with a 23 French (Fr) venous cannula and 17 Fr arterial cannula with restoration of systemic blood flow and oxygen delivery (5 L/min, 4000 rpm). Baseline pulmonary angiography demonstrated a large amount of thrombus in both the right (Movie I in the online-only Data Supplement) and the left pulmonary arteries (Figure 1; Movie II in the online-only Data Supplement). The contralateral femoral vein was cannulated with two 6 Fr sheaths and 2 Ekosonic ultrasound-accelerated thrombolysis (EKOS) catheters were placed directly into the thrombus of both pulmonary arteries (Figure 2). Local thrombolysis facilitated by ultrasound was initiated with infusion of recombinant tissue-type plasmino-gen activator at a rate of 0.5 mg/h for 24 hours in each EKOS catheter. After 6 hours of treatment, at full ECMO flow, trans-esophageal echocardiography evaluation showed persistence of right ventricular dilatation and dysfunction (tricuspid annu-lar plane systolic excursion, 9 mm; Tissue Doppler imaging, 7 cm/s). Because of the lack of hemodynamic improvement, a 1-mg bolus recombinant tissue-type plasminogen activator was administered bilaterally. According to our institutional protocol with special regard to the risk of access-related bleeding, 1 systemic anticoagulation was started after 10 hours with bivalirudin, at a rate of 0.025 mg/kg per hour and purified antithrombin supplementation was given to maintain antithrombin activity >100%. Despite the large bore vascu-lar accesses, no bleeding was noted and the patient required only 1 U of packed red blood cells. After 1 day, TEE showed complete recovery of right ventricular function and the patient was successfully decannulated the day after, with manual compression of vascular accesses. Unfortunately, anoxic brain damage as a result of the cardiac arrest was evident and the patient was discharged from hospital with severe neuro-logical sequels. Massive pulmonary embolism includes not only hypoten-sion or shock, but also pulselessness requiring cardiopulmo-nary resuscitation. 2 Resuscitation guidelines suggest …