Cardiologist National Institute of Cardiology Ignacio Chavez Tlalpan, Mexico City, Mexico
Disclosure(s):
Guadalupe L. Hernandez Gonzalez, MD: No financial relationships to disclose
Background: High-risk pulmonary embolism complicated by refractory cardiogenic shock carries high mortality despite surgical embolectomy. Mechanical circulatory support may provide hemodynamic stabilization and right ventricular unloading in selected cases. We report the first experience of veno-pulmonary ECMO as rescue therapy in this setting.
Methods: We report a single-patient case of high-risk pulmonary embolism complicated by refractory cardiogenic shock following surgical embolectomy. The patient initially underwent urgent surgical pulmonary embolectomy after clinical deterioration despite catheter-based therapy. Postoperatively, he developed persistent shock requiring high-dose inotropic and vasopressor support, severe hypoxemia with a PaO₂/FiO₂ ratio < 100, acute kidney injury requiring continuous renal replacement therapy, and recurrent episodes of ventricular tachycardia originating from the right ventricular outflow tract.
Point-of-care ultrasound and invasive hemodynamic monitoring demonstrated severe right ventricular dilation and systolic dysfunction, consistent with acute right ventricular failure. Despite maximal conventional support, the patient remained hemodynamically unstable. Given refractory shock, severe hypoxemia, and electrical instability, the multidisciplinary shock team decided to initiate veno-pulmonary extracorporeal membrane oxygenation (VP-ECMO) as rescue therapy to provide right ventricular unloading and improve pulmonary circulation.
VP-ECMO cannulation was performed under echocardiographic and fluoroscopic guidance. Hemodynamic, respiratory, renal, and neurological parameters were closely monitored.
Outcome: After initiation of VP-ECMO, the patient demonstrated rapid hemodynamic stabilization with progressive reduction in vasoactive support and improvement in oxygenation. Right ventricular performance improved, with resolution of cardiogenic shock and normalization of invasive hemodynamic parameters. No further episodes of ventricular arrhythmias were observed, and the patient remained in sustained sinus rhythm throughout the remainder of his hospitalization.
Renal function gradually recovered, allowing discontinuation of continuous renal replacement therapy. Due to prolonged invasive mechanical ventilation, a tracheostomy was performed. The patient was successfully liberated from invasive mechanical ventilation on day 16 following ECMO initiation. Progressive respiratory recovery allowed decannulation of VP-ECMO on day 37 without complications.
The subsequent clinical course was favorable, with continued recovery of cardiopulmonary function and mobilization. The patient was discharged from the hospital on day 43 in stable condition, without residual organ dysfunction or need for ongoing mechanical or pharmacologic circulatory support. At discharge, he demonstrated complete recovery from multiorgan failure and preserved functional status.
Conclusion: Veno-pulmonary ECMO can serve as an effective rescue strategy in patients with high-risk pulmonary embolism and persistent right ventricular failure after surgical embolectomy, enabling hemodynamic stabilization, recovery of organ function, and favorable clinical outcomes.
