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Description
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Surgical pulmonary embolectomy on VA-ECMO.

Rachel Steinhorn1, Adam A Dalia1, Edward A Bittner1

  • 1Massachusetts General Hospital, Department of Anesthesia, Critical Care and Pain Medicine, United States.

Respiratory Medicine Case Reports
|December 6, 2021
PubMed
Summary

Surgical pulmonary embolectomy can be safely performed using venoarterial extracorporeal membrane oxygenation (VA-ECMO) instead of cardiopulmonary bypass (CPB). This approach minimizes anticoagulation, crucial for patients with contraindications like intracranial hemorrhage.

Keywords:
ACT, activated clotting timeASD, atrial septal defectCI, cardiac indexCPB, cardiopulmonary bypassCT, computed tomographyCardiopulmonary bypassCase reportEEG, electroencephalogramExtracorporeal membrane oxygenationICU, intensive care unitLPA, left pulmonary arteryMPA, main pulmonary arteryMPAP, mean pulmonary artery pressureMRI, magnetic resonance imagingPA, pulmonary arteryPE, pulmonary embolismPERT, pulmonary embolism response teamPFO, patent foramen ovalePTT, partial thromboplastin timePulmonary embolectomyPulmonary embolismRPA, right pulmonary arterySDH, subdural hemorrhageTEE, transesophageal echocardiographyTPA, tissue plasminogen activatorVA-ECMOVA-ECMO, venoarterial extracorporeal membrane oxygenation

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Area of Science:

  • Cardiovascular Surgery
  • Critical Care Medicine
  • Interventional Cardiology

Background:

  • Surgical pulmonary embolectomy (PE) is a life-saving procedure for massive PE with circulatory collapse.
  • Traditional embolectomy uses cardiopulmonary bypass (CPB), necessitating full systemic anticoagulation.
  • Systemic anticoagulation poses risks, especially in patients with bleeding complications.

Observation:

  • A case report details a surgical pulmonary embolectomy performed on venoarterial extracorporeal membrane oxygenation (VA-ECMO).
  • The patient experienced cardiac arrest from a saddle PE and had an intracranial hemorrhage, contraindicating standard anticoagulation.
  • VA-ECMO provided cardiopulmonary support during the embolectomy, avoiding CPB and minimizing anticoagulation.

Findings:

  • The surgical pulmonary embolectomy on VA-ECMO was technically feasible and well-tolerated.
  • No procedure-related complications occurred, and ECMO support did not impede surgical performance.
  • Careful attention to volume status is critical due to the lack of a blood reservoir in VA-ECMO.

Implications:

  • VA-ECMO offers a viable alternative to CPB for surgical pulmonary embolectomy in high-risk patients.
  • This strategy is particularly beneficial for patients with massive PE and contraindications to thrombolysis or full anticoagulation.
  • It expands treatment options for critically ill PE patients requiring cardiopulmonary support.