ATS 2021 will feature presentations of original research from accepted abstracts. Mini Symposia and Thematic Poster Sessions are abstract based sessions.
Please use the form below to browse scientific abstracts and case reports accepted for ATS 2021. Abstracts presented at the ATS 2021 will be published in the Online Abstract Issue of the American Journal of Respiratory and Critical Care Medicine, Volume 203, May 3, 2021.
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Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Therapy in Acute Massive Pulmonary Embolism with Clot-In-Transit: A Case Series
Session Title
TP80 - TP080 YELLOW SUBMARINE - PULMONARY EMBOLI AND OTHER CASE REPORTS
Abstract
A3514 - Venoarterial Extracorporeal Membrane Oxygenation as a Bridge to Therapy in Acute Massive Pulmonary Embolism with Clot-In-Transit: A Case Series
Author Block: D. Sacher, O. O'Corragain, B. Lashari, D. Fleitas Sosa, S. Gayen, P. B. Desai, G. J. Criner, P. Rali; Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, United States.
Introduction:Clot-in-transit (CIT) is a rare and life-threatening embolic phenomenon more common in severe acute pulmonary embolism (PE). It is seen in approximately 18% of massive PE cases with mortality rates as high as 45%. Types of right heart thrombi are categorized by their origin, whether from deep venous thrombosis, mural thrombi in situ, or myxoma. Successful CIT management requires rapid diagnosis and treatment. Treatment options include anticoagulation, systemic thrombolysis, catheter-based therapies, or surgical embolectomy (SE). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is effective in providing circulatory support in cardiogenic shock from massive PE. We present a unique case series of acute massive PE with CIT managed by VA-ECMO as a bridge to intervention. Methods: Data was collected from a retrospective review of our single center PE response team (PERT) patient database from September 2018 to October 2020. Four patients were identified with acute PE and CIT who were managed with VA-ECMO. Results: Three men and one woman were identified with a median age of 47. Three had recent hospitalizations, and two had recent invasive procedures. Active malignancy was present in one patient, and one was postoperative from orthopedic surgery. PE was identified in the Emergency Department in half, while the other half were on the medical floors. Two patients experienced in-hospital cardiac arrest due to hemodynamic collapse from acute PE. In all patients, PE was diagnosed on computed tomography pulmonary angiography (CTPA). A CIT diagnosis was made by echocardiography in all patients. All four patients required VA-ECMO for circulatory support, either in the intensive care unit, operating room, or catheterization laboratory. All patients were treated with immediate anticoagulation, and none received systemic thrombolysis. Three patients underwent SE, and the fourth had mechanical suction thrombectomy. Mean time to VA-ECMO placement was 25 hours, and mean duration was 5 days. Only one patient suffered in-hospital morality, and the rest were discharged on long-term anticoagulation with independent functional status at 90 days. Discussion: Massive PE is a medical emergency due to hemodynamic instability and cardiogenic shock. CIT complicates management by greatly increasing mortality with increased risk of refractory obstructive shock. No clear consensus on treatment of CIT exists, with systemic thrombolysis and SE as the preferred modalities obtained from various meta-analyses. This case series demonstrates how VA-ECMO was successfully used as a periprocedural bridge to definitive PE therapy with a 75% survival rate. SE was the preferred modality at our institution.
Author Block: D. Sacher, O. O'Corragain, B. Lashari, D. Fleitas Sosa, S. Gayen, P. B. Desai, G. J. Criner, P. Rali; Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA, United States.
Introduction:Clot-in-transit (CIT) is a rare and life-threatening embolic phenomenon more common in severe acute pulmonary embolism (PE). It is seen in approximately 18% of massive PE cases with mortality rates as high as 45%. Types of right heart thrombi are categorized by their origin, whether from deep venous thrombosis, mural thrombi in situ, or myxoma. Successful CIT management requires rapid diagnosis and treatment. Treatment options include anticoagulation, systemic thrombolysis, catheter-based therapies, or surgical embolectomy (SE). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is effective in providing circulatory support in cardiogenic shock from massive PE. We present a unique case series of acute massive PE with CIT managed by VA-ECMO as a bridge to intervention. Methods: Data was collected from a retrospective review of our single center PE response team (PERT) patient database from September 2018 to October 2020. Four patients were identified with acute PE and CIT who were managed with VA-ECMO. Results: Three men and one woman were identified with a median age of 47. Three had recent hospitalizations, and two had recent invasive procedures. Active malignancy was present in one patient, and one was postoperative from orthopedic surgery. PE was identified in the Emergency Department in half, while the other half were on the medical floors. Two patients experienced in-hospital cardiac arrest due to hemodynamic collapse from acute PE. In all patients, PE was diagnosed on computed tomography pulmonary angiography (CTPA). A CIT diagnosis was made by echocardiography in all patients. All four patients required VA-ECMO for circulatory support, either in the intensive care unit, operating room, or catheterization laboratory. All patients were treated with immediate anticoagulation, and none received systemic thrombolysis. Three patients underwent SE, and the fourth had mechanical suction thrombectomy. Mean time to VA-ECMO placement was 25 hours, and mean duration was 5 days. Only one patient suffered in-hospital morality, and the rest were discharged on long-term anticoagulation with independent functional status at 90 days. Discussion: Massive PE is a medical emergency due to hemodynamic instability and cardiogenic shock. CIT complicates management by greatly increasing mortality with increased risk of refractory obstructive shock. No clear consensus on treatment of CIT exists, with systemic thrombolysis and SE as the preferred modalities obtained from various meta-analyses. This case series demonstrates how VA-ECMO was successfully used as a periprocedural bridge to definitive PE therapy with a 75% survival rate. SE was the preferred modality at our institution.
