From STEMI to saddle pulmonary embolism: Management challenges and the role of VA-ECMO

Acute pulmonary embolism and acute myocardial infarction are critical conditions with overlapping presentations, and their coexistence can be catastrophic. We report a 45-year-old man with prior mid LAD stent who presented with chest pain and ventricular fibrillation arrest, diagnosed with inferior/posterior STEMI. Emergent PCI to the mid RCA restored stability. The patient developed persistent hypoxia over the next two days requiring intubation and mechanical ventilation. Worsening hypoxia and shock prompted urgent transesophageal echocardiography to evaluate for mechanical complications, instead revealing a mobile echo density spanning the right and left main pulmonary arteries, consistent with acute saddle pulmonary embolism, and right ventricular dilation and hypokinesis. Due to rapidly progressive hypoxia and shock, he was placed on VA-ECMO and started on anticoagulation, improving without the need for urgent interventional or surgical embolectomy. This case underscores the importance of considering acute pulmonary embolism in post-myocardial infarction patients with unexplained hypoxia or shock, where overlapping features may delay diagnosis. Early VA-ECMO initiation can provide a bridge to recovery in such critically ill patients.