Advanced Therapies and Extracorporeal Membrane Oxygenation for The Management of High-Risk Pulmonary Embolism
A 67-year-old man presented to the emergency room with progressively worsening shortness of breath and chest pain of 2 days duration. He has a history of hypertension, obesity and an ischemic stroke in the right middle cerebral artery, which was treated with systemic thrombolytics 4 weeks ago, and the patient was discharged on aspirin 81 mg daily. On arrival to the emergency room, the patient was tachycardic (heart rate 122 beats per minute) and hypotensive with a blood pressure of 88/60 mmHg. His respiratory rate was 24/minute, oxygen saturation was 88% on room air and improved to 92% on 2 liters of oxygen via nasal canula. Laboratory results were notable for a normal complete blood count and comprehensive metabolic panel, high-sensitivity troponin of 57 ng/L (normal 3-15 ng/L) and N-terminal pro-brain natriuretic peptide of 685 pg/ml (normal <100 pg/ml). CT angiogram of the chest showed large bilateral pulmonary emboli. Both bed-side echocardiogram and CT angiogram of the chest showed evidence of right heart strain. The patient was started on intravenous fluids, heparin infusion and the hospital’s pulmonary embolism response team (PERT) was consulted for further management. Due to worsening respiratory status and persistent hypotension, he was intubated and started on inotropic support. Blood pressure remains low despite using maximal doses of norepinephrine and dobutamine. How should this patient be treated?
