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Review
. 2023 Jul;12(3):323-338.
doi: 10.1016/j.iccl.2023.03.004. Epub 2023 Apr 27.

Mechanical Circulatory Support and Critical Care Management of High-Risk Acute Pulmonary Embolism

Aaron A Sifuentes  1 , Ghazaleh Goldar  2 , Ahmad A Abdul-Aziz  3 , Ran Lee  2 , Supriya Shore  4
Affiliations
Review

Mechanical Circulatory Support and Critical Care Management of High-Risk Acute Pulmonary Embolism

Aaron A Sifuentes et al. Interv Cardiol Clin. 2023 Jul.

Abstract

Hemodynamically significant pulmonary embolism (PE) remains a widely prevalent, underdiagnosed condition associated with mortality rates as high as 30%. The main driver of poor outcomes is acute right ventricular failure that remains clinically challenging to diagnose and requires critical care management. Treatment of high-risk (or massive) acute PE has traditionally included systemic anticoagulation and thrombolysis. Mechanical circulatory support, including both percutaneous and surgical approaches, are emerging as treatment options for refractory shock due to acute right ventricular failure in the setting of high-risk acute pulmonary embolism.

Keywords: Mechanical circulatory support; Pulmonary embolism; Right ventricular failure.

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Conflict of interest statement

DISCLOSURE

The authors have nothing to disclose.

Figures

Fig. 1.
Fig. 1.
Pathophysiology of right ventricular failure in the setting of increased right ventricular afterload. LV, left ventricle; LVEDP, LV end-diastolic pressure; RV, right ventricle.
Fig. 2.
Fig. 2.
EKG findings in Acute Pulmonary Embolism. EKG above demonstrates a S1Q3T3 pattern, with an S wave in lead I (arrow in lead I), Q wave in lead III (left arrow in lead III), and inverted T wave in lead III (right arrow in lead III). (Image from “Pulmonary Embolism – EKG findings”.)
Fig. 3.
Fig. 3.
CT findings of right heart strain. (A) Increased RV to LV ratio and measurements, (B) Increased main PA measurements compared to the aorta, (C) bowing of interventricular septum into the LV (indicated by arrow), (D) contrast reflux into IVC (indicated by arrow). (Image from “Right heart strain assessment on CTPA following acute pulmonary embolism.”)
Fig. 4.
Fig. 4.
Infographic summary of ultrasound findings that suggest right heart strain. McConnell’s sign refers to RV mid-wall akinesia with apical sparing. (Reproduced from Alerhand S, Sundaram T, Gottlieb M. What are the echo-cardiographic findings of acute right ventricular strain that suggest pulmonary embolism?.
Fig. 5.
Fig. 5.
VA-ECMO displacing venous blood from the RA, oxygenating it via a membrane oxygenator, and returning it to the arterial circulation via the femoral artery. (Template adapted from Dr. Yevgeniy Brailovsky from Sidney Kimmel School of Medicine.)
Fig. 6.
Fig. 6.
Impella RP Device. Inlet area from the RA with outlet area in the PA, delivering blood from the RA to the PA using an axial flow pump motor. (Created with BioRender.com.)
Fig. 7.
Fig. 7.
Protek Duo dual-lumen cannula. Inflow outlet with a series of vents within the RA and superior vena cava and the outflow outlet with a fenestrated distal tip in the main PA. (Created with BioRender.com.)
Fig. 8.
Fig. 8.
Surgically implanted right ventricular assist device (RVAD) with inlet into the right atrium and outlet into the main pulmonary artery. (Created with Bio-Render.com.)
See this image and copyright information in PMC

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