Delayed intracardial shunting and hypoxemia after massive pulmonary embolism in a patient with a biventricular assist device

Refractory Hypoxemia in a Patient with Submassive Pulmonary Embolism and an Intracardiac Shunt: A Case Report and Review of the Literature

INTRODUCTION

Acute pulmonary embolism is the third leading cause of cardiovascular death. Management options include anticoagulation with or without thrombolysis. Concurrent persistent hypoxemia should be a clue to the existence of an intracardiac shunt.

CASE PRESENTATION

A 46-year-old man experienced acute hypoxemic respiratory failure requiring mechanical ventilation after anesthesia induction for elective hip arthroplasty. He was found to have submassive bilateral pulmonary emboli with acute right ventricular dysfunction and a coexisting patent foramen ovale with right-to-left shunt. He remained profoundly hypoxemic despite catheter-directed thrombolysis. He underwent surgical embolectomy with partial endarterectomy, resulting in clinical improvement.

DISCUSSION

The management of acute submassive pulmonary embolism is undertaken on an individualized basis because of the wide spectrum of clinical presentations. In this report we review the literature and discuss the evidence behind the management of cases of acute pulmonary embolism complicated by hypoxemia from a patent foramen ovale. In a case of acute pulmonary embolism complicated by refractory hypoxemia from an intracardiac shunt, adjunctive therapies in addition to anticoagulation and thrombolysis must be considered.

Tissue plasminogen activator treatment of bilateral pulmonary emboli in a pediatric patient supported with a ventricular assist device

Bleeding and thrombosis are well-known potential complications of VAD support. We present a pediatric patient who developed massive bilateral pulmonary emboli while on BiVAD support that was successfully treated with intravenous tPA and bridged to heart transplant.

Inferior vena cava filter placement before ECMO decannulation

Venous thromboembolism (VTE), particularly thrombi in the inferior vena cava (IVC) and pulmonary embolism, can occur after successful extracorporeal membrane oxygenation (ECMO) and can be associated with adverse outcomes including death. VTE is related to the presence of a venous cannula and in some cases inadequate anticoagulation caused by clinical bleeding. We have developed a simple method for guidewire exchange of the femoral venous ECMO cannula to a working catheter for intravascular ultrasound (IVUS) IVC filter placement, and describe the specific methodology.