Resident Chapel Hill, North Carolina, United States
Disclosure(s):
Connor Stephenson, MD: No financial relationships to disclose
Background: Massive pulmonary embolism (PE) accounts for 2–5% of cardiac arrests, with an estimated outside-of-hospital mortality rate ranging between 74% to 91%. Survival depends on rapid recognition and treatment. We present a cardiac arrest from massive PE complicated by right ventricular failure that resolved with prolonged cardiopulmonary resuscitation and systemic thrombolysis.
Methods: A 71-year-old female with a significant past medical history of hypertension and hyperlipidemia presented to an outside hospital emergency room with 3 hours of shortness of breath and chest discomfort while driving from Florida to New York. While transferring to her hospital room, she deteriorated into pulseless electrical activity (PEA) cardiac arrest and advanced cardiac life support (ACLS) was immediately started. Given her history and presentation, the clinical suspicion for PE was high enough to justify the use of systemic thrombolytic therapy. 40 mg of Tenecteplase (TNK) was administered shortly after the initiation of CPR. Return of spontaneous circulation (ROSC) was achieved 40 minutes after TNK was administered, however she experienced two additional PEA arrests prior to transfer to our facility, with total ACLS time greater than 70 minutes. After intubation, a CTA PE protocol demonstrated bilateral segmental and subsegmental pulmonary emboli involving all lobes with evidence of significant right heart strain. Upon confirmation of massive PE, she was transferred to our tertiary care center for consideration of mechanical thrombectomy.
Outcome: A repeat CTA PE protocol upon arrival demonstrated significant improvement in proximal clot burden negating the utility of mechanical thrombectomy. However, despite this improvement she continued to experience significant hemodynamic instability requiring multi-vasopressor support (norepinephrine, vasopressin, and epinephrine infusions). A formal echocardiogram shortly after arrival demonstrated a normal LVEF (> 55%) but confirmed a dilatated right ventricle (RV) with reduced systolic function, raising the concern for RV failure as the etiology of her continued shock. A subsequent right heart catheterization demonstrated normal right-sided filling pressures with a pulmonary artery pulsatility index (PAPI) greater than 2; therefore, implantation of a right ventricular mechanical assist device was deferred. She was returned to the CICU with a pulmonary artery catheter (PAC) for further hemodynamic monitoring while undergoing preload optimization. After receiving IV fluids with PAC guidance, she was able to wean off her vasopressor infusions and was extubated. Her hospital course was otherwise uncomplicated, and she made a full neurological recovery prior to discharge.
Conclusion: Current guidelines do not clearly define the duration of ACLS after thrombolysis in PE-related cardiac arrest. European Society of Cardiology suggest 60–90 minutes of resuscitation, while American governing bodies provide no recommendation. This case supports the notion that thrombolysis paired with prolonged resuscitation can enable survival with full neurological recovery.
