Bivalirudin and Alteplase for Pulmonary Embolism Requiring Veno-Arterial Extracorporeal Membrane Oxygenation in an Adolescent

Abstract

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.

Keywords: alteplase; anticoagulation; bivalirudin; children; direct thrombin inhibitor; pediatric; pulmonary embolism; thrombolysis; veno-arterial extracorporeal membrane oxygenation.

Figure 1.

Pretreatment: Bilateral pulmonary embolus with significant enlargement of the main PA and area of pulmonary infarction (A, top). Significant enlargement of the RV with straightening of the ventricular septum and decreased left ventricle size (A, bottom). Initial pulmonary angiogram showing significant bilateral PE and right heart dysfunction (B, top). Persistent bilateral lobar and segmental pulmonary emboli on follow-up pulmonary angiogram (B, bottom). Initial posttreatment CT showing persistent but decreased clot burden (C, top). Three-month follow-up CT shows significant reduction in clot burden with minimal lobar and segmental emboli (C, bottom). PA, pulmonary artery; RV, right ventricle; PE, pulmonary embolism; CT, computed tomography.