Cardiac arrest from massive PE in nephrotic syndrome successfully treated with embolectomy and ECMO
Crit Care Med
Learning Objectives: Pulmonary emboli (PE) are commonly encountered events with presentations ranging from benign incidental findings to obstructive shock. We present a case of a 20 year old male with nephrotic syndrome who suffered complete cardiovascular collapse with cardiac arrest in the setting of a massive PE, requiring open surgical embolectomy and ECMO support. We reviewed the literature on massive PE's focusing on the use of ECMO and success of the rarely performed open embolectomy for the treatment of obstructive shock from a massive PE. Methods: 20 year old male with a history of nephrotic syndrome presented to the emergency department (ED) with complaints of abdominal discomfort and fatigue. The patient had a syncopal episode in the ED and became tachycardic, hypotensive, tachypneic, hypoxic and cool to touch. He was admitted to the MICU where troponin increased from 0.06 to 2.87ng/mL, BNP was 150 pg/mL, EKG demonstrated RBBB with right heart strain pattern, bedside US showed a massive RV with bowing septum and CT PE demonstrated a massive saddle PE with RV strain. The patient became increasingly unstable requiring maximal vasopressor support and intubation, and ultimately had a PEA arrest en route to the OR for emergent open embolectomy. He received 30 minutes of open cardiac massage with surgical removal of large clot burden. Patient was placed on VA ECMO due to RV failure and cor pulmonale. He was stabilized and able to be decannulated from ECMO 7 days later. He was discharged to subacute rehab with all of his faculties. Results: The presentation of a pulmonary embolus (PE) can range from benign to complete cardiovascular collapse. With the increasing frequency of diagnosed PE's, treatment modalities have also been evolving. For massive PE's with hemodynamic instability patients can be treated with systemic tPA or by surgical embolectomy. Although uncommonly seen in medical practice, several case reviews of massive PE's demonstrated overall positive outcomes following surgery. Open embolectomies are rarely performed, however, as patients are often either too ill to survive to the operating table or are well-enough for less invasive therapies such as catheter-directed lysis. ECMO is occasionally performed in cases of massive PE as a temporizing measure to embolectomy but has also been used successfully for ongoing RV failure following embolectomy, such as in our patient.