QW38-May 2025

Question: Select each option to validate with explanations

Clinical Case Scenario

A 68-year-old male presents to the ED with acute onset of severe dyspnoea, pleuritic chest pain, and lightheadedness. He has a history of recent prolonged immobility. Upon arrival, he is hypotensive (BP, 70/40 mmHg), tachycardic (HR, 130 bpm), tachypneic (RR, 38 bpm), and profoundly hypoxemic (SpO2, 78% on room air), requiring immediate tracheal intubation. Physical exam reveals a swollen, tender right lower extremity. Initial labs show a significantly elevated D-dimer and a platelet count of 65,000/µL. A lower limb Doppler reveals a deep venous thrombosis (DVT) in the bilateral proximal femoral veins. An immediate CT pulmonary angiogram (CTPA) reveals a large saddle pulmonary embolus (PE) with significant right ventricular strain.

Question: Which of the following is the most appropriate management option at this time point?

a. Only systemic thrombolysis

b. Systemic thrombolysis with additional mechanical circulatory support (MCS) with use of Impella-RP

c. Systemic thrombolysis with additional mechanical circulatory support (MCS) with use of Protek-Duo (check whether to add Impella-CP instead of Protek-Duo)

d. Catheter-directed thrombolysis with use of VA-ECMO

Wrong Answer: Given the severe cardiac and respiratory failure, systemic thrombolysis alone without mechanical circulatory support (MCS) is insufficient for recovery. Furthermore, severe thrombocytopenia due to associated high bleeding risk contraindicates systemic thrombolysis.

Wrong Answer: Mechanical circulatory support (MCS) with Impella-CP offers only cardiac support, making it unsuitable for this patient, who also requires respiratory assistance. Furthermore, due to severe thrombocytopenia and the associated high bleeding risk, systemic thrombolysis should be avoided.

Wrong Answer: Unlike some other devices that might only provide cardiac support (like Impella-CP), the ProtekDuo can be connected to an oxygenator. Thus, the ProtekDuo can provide both cardiac and respiratory support. This would be ideal for the current scenario of the patient. However, due to severe thrombocytopenia and the associated high bleeding risk, systemic thrombolysis should be avoided.

Right Answer:For this patient, catheter-directed thrombolysis (CDT) would be preferred over systemic thrombolysis due to its lower bleeding risk, especially with this patient having associated thrombocytopenia. VA-ECMO is the ideal mechanical circulatory support (MCS) as it provides both heart and lung support. While VA-ECMO still requires anticoagulation, its bleeding risk is significantly less than that associated with systemic thrombolysis. .

Explaination
The scenario is of a patient with DVT and high-risk massive PE with additional thrombocytopenia (with high bleeding risk). In view of refractory shock and respiratory failure, this patient will need mechanical circulatory support (MCS). The management of acute high-risk pulmonary embolism and circulatory failure using MCS is summarised in figure 1 below. The level of respiratory support that can be provided by the MCS devices has been summarised in table 1 below.

Clinical pearl:
● High-risk PE with circulatory failure may need assistance with MCS
● The correct type of MCS selection is crucial by considering factors such as bleeding tendency and additional need of respiratory support
● Although there is no ‘one-size-fits-all’ approach, the correct MCS device selection should take into consideration the risks versus benefits

Reference:

1. Mentzel L, Fengler K, Oezkur M, et al. Mechanical circulatory support in acute pulmonary embolism. Eur Heart J Suppl. 2025;27(Suppl 4):iv47-iv54. Published 2025 Feb 4. doi:10.1093/eurheartjsupp/suaf001
2. Schroeder SE. Mechanical Circulatory Support Therapy in the Cardiac Intensive Care Unit. Nurs Clin North Am. 2023;58(3):421-437. doi:10.1016/j.cnur.2023.05.008
3. Papolos AI, Barnett CF, Tuli A, Vavilin I, Kenigsberg BB. Impella Management for the Cardiac Intensivist. ASAIO J. 2022;68(6):753-758. doi:10.1097/MAT.0000000000001680

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