“Dr Kon- VA-ECMO for massive pulmonary embolism” From The Maryland Critical Care Project

Dr Kon- VA-ECMO for massive pulmonary embolism from the Maryland Critical Care Project:

Today we welcome Zachary Kon, M.D., Assistant Professor in the Department of Cardiothoracic Surgery at NYU. In addition to acting as the Surgical Director of Pulmonary Hypertension/Pulmonary Thromboendarterectomy Program, Dr. Kon also acts as the Surgical Director of the NYU Lung Transplantation Program. In addition to > 70 peer-reviewed publications, he has been invited all over the world as an expert speaker in the field pulmonary embolism therapy. We are fortunate to have him in-house to share his knowledge of what to do when the PE is starting to become overwhelming!


Clinical Pearls

  • Massive PE is defined by HD instability
    • It is the HD compromise, not the hypoxia, that leads to morbidity/mortality
    • Surgical embolectomy has become a mainstay of treatment (mortality as low as 5-10%)
      • Intubation worsens mortality!  
  • Submassive PE is HD stable with RV strain/dysfunction (TTE, CT scan, troponin/BNP)
  • VA-ECMO use has facilitated decompression of the right heart and improved outcomes
    • Potential triage of patients who would benefit from embolectomy
      • Algorithm: ECMO is initial strategy to recover organ function and either wean to survival, embolectomy, or to withdrawal of care.
      • Decreased mortality (3% vs. 23%), decreased time from arrest to intervention (4 hrs vs. 11.5 hrs), and decreased need for surgical embolectomy (55% vs. 100%)

The Annals of Thoracic Surgery 2018 105, 498-504

    • RV recovery on VA-ECMO dictated by:
      • History of prior PE
      • Chronic DVT (> 2 weeks)
      • Higher BNP on presentation (not troponin!)
  • Fallacies
    1. Too peripheral
      • Distal, sub-segmental vessels can be accessed and removed
    2. Too invasive
      • Minimally invasive approaches (5-7 cm incisions) can be used with excellent outcomes
        • Hospital LOS: 4 days
    3. Can’t rehabilitate 
      • Cannulation does NOT require intubation
      • All non-intubated ECMO pts can mobilize
  • Random facts to know!
    • Anatomic distribution or burden of clot DOES NOT correlate to clinical outcomes
    • Chronic thromboembolic pulm HTN (CTEP) risk is 3%, though 5-10x the risk when presenting with pulm HTN + acute PE!
      • Submassive PE + simple AC = > 50% risk for CTEP vs > 15% with thrombolysis (MOPETT)
      • As PA pressure continues to increase, mortality worsens
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