B64-48 Massive Pulmonary Embolism With Refractory Right Ventricular (RV) Failure Despite Therapeutic Apixaban: The Institution’s First RV Impella Case

Abstract Background Direct oral anticoagulants (DOACs) like apixaban offer reliable protection against venous thromboembolism (VTE), and therapeutic failures are rare. Massive pulmonary embolism (PE) complicated by refractory right ventricular (RV) failure carries high mortality despite reperfusion. Mechanical circulatory support options include veno-arterial extracorporeal membranous oxygenation (VA ECMO) and temporary oxy-right ventricular assist devices (RVAD) such as ProtekDuo™ (LivaNova). An emerging adjunct is the Impella RP Flex, a temporary RVAD without oxygenation capacity (Abiomed). Case Presentation A 73-year-old man on apixaban for atrial fibrillation (AF) presented with syncope and dyspnea to a small rural hospital in our area. His initial diagnosis was AF with rapid ventricular rate and non-ST elevation myocardial infarction. He was transferred to our facility for worsening hypoxia and hypotension requiring vasopressors. He arrived with cool extremities, elevated lactic acid (5.6 mmol/L), D-dimer 20, and NT-proBNP 34,000 pg/mL, indicating shock. Despite a therapeutic anti-Xa level (118 ng/mL), CTA chest showed bilateral central PE, and a transthoracic echocardiogram showed severe RV systolic dysfunction and intraventricular septal flattening. He underwent emergency mechanical Inari™ thrombectomy, but his oxygenation and shock state failed to improve. After a multidisciplinary risk-benefit conversation with the patient’s family, the decision was made to place an Impella RP Flex to stabilize the patient, the first in our institution’s history. The device improved perfusion and hemodynamics. The patient was successfully weaned from inhaled pulmonary vasodilators and vasopressors, requiring only dobutamine for RV systolic support. Due to the inability to wean the Impella RP Flex, poor RV function, and the femoral implantation site limiting mobility, the patient was transferred for an oxyRVAD (ProtekDuo™) upgrade. Discussion True DOAC failure despite therapeutic apixaban levels is rare but may result in catastrophic complications. Additionally, the RV Impella can bridge isolated RV failure caused by massive PE when conventional measures are ineffective. However, device choice has implications for patient mobility and rehabilitation. The ProtekDuo™ allows ambulation and participation in physical therapy while providing circulatory and respiratory support. Early mobilization in mechanically supported patients is associated with shorter ICU length of stay and improved recovery. While the Impella RP offers valuable short-term rescue, the ProtekDuo™ may be a more versatile and rehabilitative option. This case highlights the need to recognize and escalate mechanical support in DOAC failure with massive PE-induced RV failure. For select patients, transitioning from Impella RP Flex to an oxyRVAD may optimize both hemodynamics and rehabilitation potential. This abstract is funded by: None