(242) Impella RP as a Bridge to Recovery in Massive Bilateral Pulmonary Embolism

Introduction: Acute pulmonary embolism is a common cause of cardiovascular mortality and is the third most common type of cardiovascular disease. The global burden of VTE is estimated to be around 10 million cases per year.
In patients presenting with massive pulmonary embolism, stabilization of hemodynamics is a pressing issue as these patients are in overt right heart failure. In this abstract we present a case of massive pulmonary embolism with subsequent acute right sided heart failure (AHRF) which was managed with a right sided impella as a rescue measure.

Description: A 79 year old male presented after having a syncopal episode at home. On arrival at the ED the patient had regained consciousness and complained of severe chest pain. D-dimer was done which was elevated at 23.9 mg/L and CTPE showed bilateral pulmonary embolism with right heart strain. Patient was taken for IR thrombectomy. Patient coded during the procedure, was intubated, and after one dose of epinephrine ROSC was achieved. He was started on norepinephrine due to persistent hypotension. Labs showed lactic acidosis of 9 mmol/L and pH of 6.9. Due to increasing pressor requirements and RV failure on echocardiogram, the patient was deemed a candidate for Impella RP. After insertion, his hemodynamic status improved; with decreasing pressor requirements. He was then transferred to a tertiary care center for transition to VA-ECMO.

Discussion: Acute RV failure in the setting of acute massive PE has significant mortality, despite measures to aggressively treat PE, the damage and catastrophic downstream effects of RV failure are massively dangerous. As in this case, the utilization of Impella RP comes in as a bridge to recovery of RV function. The Impella RP is FDA approved for circulatory support in acute RV failure. In our patient, pulmonary artery pulsatile index significantly improved from 0.8 to 2.3 after insertion. There are a few documented cases of impella RP in acute PE and this case aims to highlight its utility as a bridge to recovery in cases where ECMO is unavailable or patients are not a candidate.