(1544) Extracorporeal Cardiopulmonary Resuscitation (ECPR) for intermediate-Risk Pulmonary Embolisms (PE)

Introduction: Pulmonary Embolism (PE) is the 3rd leading cause of cardiovascular death. Extracorporeal membrane oxygenation (ECMO) can provide circulatory support as a bridge to further treatment for PE. There is insufficient evidence, however, for its use in intermediate-risk PE. We present a case-series of intermediate-risk PE with deterioration managed successfully with extracorporeal cardiopulmonary resuscitation (E-CPR).

Description: Case 1, a 54 y/o male presented with dyspnea and hypoxia. He was found to have a saddle PE with right ventricular (RV) strain and troponinemia but remained hemodynamically stable. While on anticoagulation, he developed sudden cardiac arrest and underwent E-CPR. After emergent pulmonary thrombectomy and a week of ECMO support, he was decannulated and eventually discharged home after cardiac recovery.  

Case 2, a 41 y/o male developed hypoxia while mechanically ventilated and recovering from a complex abdominal surgery. He was found to have a large PE on CT and RV dilation without shock. During a percutaneous thrombectomy, he went into cardiac arrest requiring E-CPR. Patient had a prolonged hospital course requiring a repeat pulmonary thrombectomy, and multiple ECMO reconfigurations. He was successfully decannulated and discharged home after functional recovery.

Case 3, a 73 y/o female with high-grade cancer presented with dyspnea and was found to have large bilateral PEs on surveillance CT with RV dilation and elevated pro-Brain Natriuretic Peptide (pro-BNP). She underwent non-emergent pulmonary thrombectomy complicated by pulmonary hemorrhage and cardiac arrest requiring E-CPR. Despite needing an additional thrombectomy, she clinically improved and was decannulated. Unfortunately, due to continued multiorgan dysfunction requiring prolonged ventilator and dialysis support, the patient’s family decided to proceed with comfort care.

Discussion: E-CPR in patients with intermediate-risk PE can be a lifesaving strategy. Success in such critical scenarios is contingent on a multidisciplinary approach, sufficient resources, and prompt management of sequalae. Our case series promotes the potential of ECMO, with careful patient selection and better timing of ECMO deployment, in improving outcomes while limiting complications in this population.