Key result
Catheter thrombolysis alongside VA-ECMO, bivalirudin, and systemic alteplase led to successful resolution of saddle pulmonary embolism and weaning off VA-ECMO in a 17-year-old patient.
Why the study?
Saddle PE remains challenging to diagnose and manage in pediatric patients, and pediatricians may be unaware of therapies increasingly used in adults such as VA-ECMO with systemic and local thrombolysis.
Case Report (n=1)
No
The concurrent use of bivalirudin for ECMO anticoagulation alongside systemic and catheter-directed alteplase thrombolysis successfully treated a high-risk saddle pulmonary embolism in a pediatric patient.
Supports feasibility in pediatric high-risk PE on VA-ECMO; hypothesis-generating and requires prospective trials before adoption.
Saddle pulmonary embolism (PE) remains a challenge to diagnose and manage in pediatric patients. Current literature encourages early consideration of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in high-risk PE patients with impending right ventricular failure. We present a 17-year-old patient who was admitted to a pediatric cardiac intensive care unit with saddle PE requiring emergent VA-ECMO support because of cardiovascular collapse. Despite anticoagulation with bivalirudin and receiving systemic thrombolysis with alteplase, the clot burden was persistent with minimal improvement in right ventricular function. We proceeded to catheter thrombolysis while on VA-ECMO. This ultimately led to a successful resolution of the PE and allowed for weaning off VA-ECMO. PE is rare in children compared with adults, and pediatricians may be unaware of therapies becoming increasingly used in adults such as the use of VA-ECMO, with systemic and local thrombolysis. The concurrent use of a direct thrombin inhibitor for ECMO anticoagulation alongside the thrombolysis is a novel combination in this condition and age-group.
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Machado et al. (2020) conducted a case report in Saddle pulmonary embolism (n=1). Catheter thrombolysis, bivalirudin, and systemic alteplase on VA-ECMO was evaluated on Resolution of PE and weaning off VA-ECMO. Catheter thrombolysis alongside VA-ECMO, bivalirudin, and systemic alteplase led to successful resolution of saddle pulmonary embolism and weaning off VA-ECMO in a 17-year-old patient.
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