Bishnoi, Sonali

Blumof, Scott, DO

Lam, Amy, DO

Musco, Kaitlyn, MD

Wright, Jeffrey, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine on’t Take My Breath Away: A Case of High-Risk Pulmonary Embolism in the Setting of Patent Foramen Ovale Requiring Extracorporeal Membrane Oxygenation Amy Lam DO Sonali Bishnoi Jeffrey Wright DO Kaitlyn Musco MD Scott Blumof DO Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Medicine and Health Sciences Commons This Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Presented atDon’t Take My Breath Away: A Case of High-Risk Pulmonary Embolism in the Setting of Patent Foramen Ovale Requiring Extracorporeal Membrane OxygenationAmy Lam, DO,1 Sonali Bishnoi, DO,1 Jeffrey Wright, DO,1 Kaitlyn Musco, MD,2 Scott Blumhof, DO21Department of Internal Medicine, 2Division of Pulmonary and Critical Care Medicine, Lehigh Valley Health Network, Allentown, PA BACKGROUND• Pulmonary emboli (PE) is the third most common cause of cardiovascular death, with 60,000-100,000 deaths per year. • Approximately 35% of the general population have a patent foramen ovale (PFO) based on autopsy studies.• We present a case of a patient with saddle pulmonary emboli who had persistent hypoxemia in the setting of a PFO.CASE DESCRIPTIONA 67-year-old man with a past medical history of coronary artery disease, alcohol abuse, hypertension, hyperlipidemia, and obstructive sleep apnea presented to the hospital with complaint of word-finding difficulty and behavioral changes. He was found to have acute occlusion of the bilateral middle cerebral arteries, requiring mechanical thrombectomy. He was recovering successfully when he suddenly developed dyspnea and lightheadedness with exertion, which rapidly progressed to mechanical ventilation. He remained hypoxic on optimal ventilator settings and inhaled nitric oxide, prompting suspicion for acute pulmonary embolism. Chest x-ray was unchanged. EKG showed inferior ST-segment elevations.  Emergent transesophageal echocardiogram (TEE) revealed a severely dilated right ventricle, an underfilled left ventricle, McConnell’s sign, and right to left atrial septal bowing suggesting elevated right atrial pressures.  TEE also noted an incidental PFO with right-to-left shunting and an atrial septal aneurysm. Computed tomography scan of the chest revealed a saddle pulmonary embolus. Veno-arterial extracorporeal membrane oxygenation (ECMO) was initiated as a bridge to mechanical thrombectomy. He was converted from veno-arterial ECMO to veno-venous ECMO with Protek Duo for right ventricular support.  His hospital course was complicated by cardiogenic shock, septic shock, and progression of his initial ischemic stroke. He was able to be decannulated from ECMO and eventually extubated.  He was discharged to a long-term care facility. DISCUSSION• Pulmonary emboli (PE) can precipitate cardiovascular collapse by mechanical obstruction of the right ventricular outflow tract and pulmonary artery vasoconstriction, leading to right ventricular overload. The presence of a patent foramen ovale (PFO) can subvert this typical physiology by creating a right-to-left shunt, permitting left ventricular filling and near-normal cardiac output. However, this also causes intracardiac mixing of oxygenated and deoxygenated blood, which can further worsen hypoxemia. • Recent studies have recognized ECMO as a promising adjunctive therapy for pulmonary emboli for those who are too unstable for surgical thrombectomy or who have contraindications to systemic thrombolysis. Our patient was not a candidate for thrombolysis given his recent stroke. • The patient’s PFO, while beneficial in preventing florid cardiogenic shock by offloading the right ventricle, caused hypoxemia refractory to mechanical ventilation alone. Thus, ECMO was a crucial temporizing measure for bridging to surgical thrombectomy. CONCLUSION• It is important to have high clinical suspicion for intracardiac shunts in cases of refractory hypoxemia in pulmonary emboli. This aid with early  identification of patients who need advanced intervention such as ECMO.Transesophageal echocardiogram demonstrated dilated right side of the heart and patent foramen ovale by color Doppler flow Computed tomography scan of the chest revealed saddle pulmonary emboliRefractory hypoxemia in pulmonary emboli should prompt high clinical suspicion for the presence of intracardiac shunts1. Al-Bawardy R, Rosenfield K, Borges J, Young MN, Albaghdadi M, Rosovsky R, Kabrhel C. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a case series and review of the literature. Perfusion. 2019 Jan;34(1):22-28. doi: 10.1177/0267659118786830. Epub 2018 Jul 16. PMID: 30009670.2. Askari K, Sneij W, Krick S, Alvarez RA. Going with the Flow: Saddle Pulmonary Embolism Complicated by Severe Hypoxemia without Shock. Annals of the American Thoracic Society. 2017;14(9):1479-1484. doi:10.1513/annalsats.201702-145cc3. Corsi F, Lebreton G, Bréchot N, Hekimian G, Nieszkowska A, Trouillet JL, Luyt CE, Leprince P, Chastre J, Combes A, Schmidt M. Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation. Crit Care. 2017 Mar 28;21(1):76. doi: 10.1186/s13054-017-1655-8. PMID: 28347320; PMCID: PMC53692164. George B, Parazino M, Omar HR, Davis G, Guglin M, Gurley J, Smyth S. A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support. Resuscitation. 2018 Jan;122:1-5. doi: 10.1016/j.resuscitation.2017.11.034. Epub 2017 Nov 8. PMID: 29128608.5. Granati GT, Teressa G. Worsening Hypoxemia in the Face of Increasing PEEP: A Case of Large Pulmonary Embolism in the Setting of Intracardiac Shunt. Am J Case Rep. 2016;17:454-458. Published 2016 Jul 5. doi:10.12659/ajcr.8985216. Liew J, Stevens J, Slatore C. Refractory Hypoxemia in a Patient with Submassive Pulmonary Embolism and an Intracardiac Shunt: A Case Report and Review of the Literature. Perm J. 2018;22:17-061. doi:10.7812/TPP/17-0617. Newman J, Park D, Manetta F. Extracorporeal membrane oxygenation for failed tPA therapy of pulmonary embolism.8. Weinberg A, Tapson VF, Ramzy D. Massive Pulmonary Embolism: Extracorporeal Membrane Oxygenation and Surgical Pulmonary Embolectomy. Semin Respir Crit Care Med. 2017 Feb;38(1):66-72. doi: 10.1055/s-0036-1597559. Epub 2017 Feb 16. PMID: 28208200.9. Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion. 2015 Nov;30(8):611-6. doi: 10.1177/0267659115583377. Epub 2015 Apr 24. PMID: 25910837.10. Gutierrez Bernal A, Fanola C, Bartos JA. Management of PE. American College of Cardiology. https://www.acc.org/latest-in-cardiology/articles/2020/01/27/07/42/management-of-pe. Published January 27, 2020. Accessed April 10, 2021.

on’t Take My Breath Away: A Case of High-Risk Pulmonary Embolism in the Setting of  Patent Foramen Ovale Requiring Extracorporeal Membrane Oxygenation

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on’t Take My Breath Away: A Case of High-Risk Pulmonary Embolism in the Setting of Patent Foramen Ovale Requiring Extracorporeal Membrane Oxygenation

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