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Zhang X, Huangfu Z. Management of pregnant patients with pulmonary arterial hypertension. Front Cardiovasc Med 2022; 9:1029057. [PMID: 36440029 PMCID: PMC9684470 DOI: 10.3389/fcvm.2022.1029057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 10/27/2022] [Indexed: 09/19/2023] Open
Abstract
Pregnant individuals with pulmonary arterial hypertension (PAH) have significantly high risks of maternal and perinatal mortality. Profound changes in plasma volume, cardiac output and systemic vascular resistance can all increase the strain being placed on the right ventricle, leading to heart failure and cardiovascular collapse. Given the complex network of opposing physiological changes, strict contraception and reduction of hemodynamic fluctuations during pregnancy are important methods of minimizing the risk of maternal mortality and improving the outcomes following pregnancy. In this review, we discuss the recent research progress into pre-conception management and the various therapeutic strategies for pregnant individuals with PAH.
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Affiliation(s)
- Xiao Zhang
- Department of Gynecology and Obstetrics, Beijing Hospital, National Center of Gerontology, Beijing, China
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Peking Union Medical College, Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhao Huangfu
- Department of Urology, Changhai Hospital, Naval Medical University, Shanghai, China
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2
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Lewis AE, Gerstein NS, Venkataramani R, Ramakrishna H. Evolving Management Trends and Outcomes in Catheter Management of Acute Pulmonary Embolism. J Cardiothorac Vasc Anesth 2021; 36:3344-3356. [PMID: 34696967 PMCID: PMC8487849 DOI: 10.1053/j.jvca.2021.09.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Alexander E Lewis
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM
| | - Neal S Gerstein
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM
| | - Ranjani Venkataramani
- Department of Anesthesiology and Critical Care Medicine, University of New Mexico, Albuquerque, NM
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Rodriguez D, Jerjes-Sanchez C, Fonseca S, Garcia-Toto R, Martinez-Alvarado J, Panneflek J, Ortiz-Ledesma C, Nevarez F. Thrombolysis in massive and submassive pulmonary embolism during pregnancy and the puerperium: a systematic review. J Thromb Thrombolysis 2021; 50:929-941. [PMID: 32347509 DOI: 10.1007/s11239-020-02122-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Thrombolysis in high-risk pulmonary embolism (PE) patients is recommended worldwide; however, the evidence for thrombolysis during pregnancy and the immediate puerperium remains unclear. We conducted a systematic review from 1950 to 2019 through PubMed, Ovid/Willey, and Cochrane Library to assess the safety and effectiveness of thrombolysis during pregnancy and the immediate puerperium. Additionally, we characterized the clinical presentation, risk stratification, and diagnostic approach. We have communicated our results according to the PRISMA statement. We collected 141 records and, after critical assessment, included 47 case reports of 54 patients, including 43 and 11 patients during pregnancy and puerperium, respectively. During pregnancy, alteplase was the most frequent systemic thrombolytic agent used (67%), but only nine patients received the approved FDA regimen. With catheter-directed thrombolysis, low-dose thrombolytics and fragmentation were the most common regimens. Major bleeding occurred in 18% of cases, but there was no intracranial bleeding. One maternal death occurred secondary to refractory cardiogenic shock. Fetal mortality was 20%. During the immediate puerperium, nine patients received "off-label" first-, second-, and third-generation thrombolytic regimens, and four cases underwent catheter-directed thrombolysis. We observed nine major bleeding events, seven of which were from the uterine location and none of which were intracranial. In conclusion, overall, these data do not suggest prohibitive risk associated with thrombolysis for PE in pregnancy. Management of massive and high-risk submassive PE in pregnancy should be individualized to each patient. In the data presented, no fatal bleeding or intracranial bleeding was observed. Finally, future efforts should systematically collect and report data on high-risk PE in pregnancy and peripartum patients to improve the evidence-base clinical practice.
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Affiliation(s)
- David Rodriguez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico
| | - Carlos Jerjes-Sanchez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico.
- Centro de Investigacion Biomedica del Hospital Zambrano Hellion, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Instituto de Cardiología y Medicina Vascular, TecSalud, San Pedro Garza García, Nuevo Leon, Mexico.
- Hospital Zambrano Hellion, Batallón de San Patricio 112, Real San Agustin, San Pedro Garza Garcia, Nuevo Leon, 66278, Mexico.
| | - Sugely Fonseca
- Internal Medicine, Hospital San José, TecSalud, Nuevo Leon, Monterrey, Mexico
| | | | | | | | - Claudia Ortiz-Ledesma
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
| | - Francisco Nevarez
- Escuela de Medicina y Ciencias de La Salud, Tecnologico de Monterrey, Monterrey, Nuevo Leon, Mexico
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Sebastian NA, Spence AR, Bouhadoun S, Abenhaim HA. Extracorporeal membrane oxygenation in pregnant and postpartum patients: a systematic review. J Matern Fetal Neonatal Med 2020; 35:4663-4673. [PMID: 33345652 DOI: 10.1080/14767058.2020.1860932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE Information on the use of extracorporeal membrane oxygenation (ECMO) in obstetric patients is scarce. The objective was to conduct a systematic review examining ECMO use in pregnant and postpartum patients in order to identify indications leading to ECMO use and to assess mortality rates. MATERIALS AND METHODS PubMed, EMBASE, Cochrane Library, and SCOPUS were searched using the terms "extracorporeal membrane oxygenation" and "pregnancy" up to 1 November 2020. Case reports and case series reporting the use of ECMO in pregnancy were eligible. Data about maternal age, gestational age, diagnosis, type of ECMO, time on ECMO, pregnancy outcomes, and maternal survival were extracted from studies. RESULTS The search yielded 1696 citations, of which 125 were included. There were 213 obstetric patients treated with ECMO over a 30-year period. The frequency of reports increased considerably over the last decade. The majority of patients were treated in their third trimester (28.2%) or postpartum (32.9%). Most common etiologies included influenza-induced ARDS (27.7%), pulmonary embolism (13.6%), peripartum cardiomyopathy (11.7%), and infection (11.7%). Pregnancy outcomes ended with live births, either on ECMO (15.5%, 95% CI 10.6-20.4) or not on ECMO (58.3%, 95% CI 51.7-64.9), in fetal demise (8.9%, 95% CI 5.1-12.7), or in spontaneous or induced abortion on ECMO (4.2%, 95% CI 1.5-6.9) or not on ECMO (4.2%, 95% CI 1.5-6.9). Maternal survival was 79.3%. CONCLUSION Although women placed on ECMO had a high mortality rate, this is likely an indication of the severity of illness. Overall, ECMO appears to be a valid therapy for the temporary support of vital organs in severely ill pregnant women.
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Affiliation(s)
- Natasha A Sebastian
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Andrea R Spence
- Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
| | - Sarah Bouhadoun
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.,Centre for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada
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Naoum EE, Chalupka A, Haft J, MacEachern M, Vandeven CJM, Easter SR, Maile M, Bateman BT, Bauer ME. Extracorporeal Life Support in Pregnancy: A Systematic Review. J Am Heart Assoc 2020; 9:e016072. [PMID: 32578471 PMCID: PMC7670512 DOI: 10.1161/jaha.119.016072] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background The use of extracorporeal life support (ECLS) has expanded to include unique populations such as peripartum women. This systematic review aims to (1) quantify the number of cases and indications for ECLS in women during the peripartum period reported in the literature and (2) report maternal and fetal complications and outcomes associated with peripartum ECLS. Methods and Results This review was registered in PROSPERO (CRD42018108142). MEDLINE, Embase, and CINAHL were searched for case reports, case series, and studies reporting cases of ECLS during the peripartum period that reported one or more of the following outcomes: maternal survival, maternal complications, fetal survival, and/or fetal complications. Qualitative assessment of 221 publications evaluated the number of cases, clinical details, and maternal and fetal outcomes of ECLS during the peripartum period. There were 358 women included and 68 reported fetal outcomes in cases where the mother was pregnant at the time of cannulation. The aggregate maternal survival at 30 days was 270 (75.4%) and at 1 year was 266 (74.3%); fetal survival was 44 (64.7%). The most common indications for ECLS overall in pregnancy included acute respiratory distress syndrome 177 (49.4%), cardiac failure 67 (18.7%), and cardiac arrest 57 (15.9%). The most common maternal complications included mild to moderate bleeding 66 (18.4%), severe bleeding requiring surgical intervention 48 (13.4%), and intracranial neurologic morbidity 19 (5.3%). The most commonly reported fetal complications included preterm delivery 33 (48.5%) and neonatal intensive care unit admission 19 (27.9%). Conclusions Reported rates of survival in ECLS in pregnant and postpartum women are high and major complications relatively low.
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Affiliation(s)
- Emily E. Naoum
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Andrew Chalupka
- Department of Anesthesia, Critical Care and Pain MedicineMassachusetts General HospitalBostonMA
| | - Jonathan Haft
- Department of Cardiac SurgeryUniversity of MichiganAnn ArborMI
| | - Mark MacEachern
- Taubman Health Sciences LibraryUniversity of MichiganAnn ArborMI
| | - Cosmas J. M. Vandeven
- Department of Obstetrics and GynecologyMaternal‐Fetal MedicineUniversity of MichiganAnn ArborMI
| | - Sarah Rae Easter
- Division of Maternal‐Fetal MedicineDepartment of Obstetrics and GynecologyBrigham and Women’s HospitalBostonMA
| | - Michael Maile
- Department of AnesthesiologyUniversity of MichiganAnn ArborMI
| | - Brian T. Bateman
- Division of Pharmacoepidemiology and PharmacoeconomicsDepartment of MedicineDepartment of Anesthesiology, Perioperative and Pain MedicineBrigham and Women’s HospitalBostonMA
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Extracorporeal Life Support as Salvage Therapy for Massive Pulmonary Embolus and Cardiac Arrest in Pregnancy. J Emerg Med 2018; 55:121-124. [PMID: 29739630 DOI: 10.1016/j.jemermed.2018.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/26/2018] [Accepted: 04/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Massive pulmonary embolus (PE) with prolonged cardiac arrest in the setting of pregnancy has few treatment options. Selections are further restricted if there are contraindications to the standard therapies of embolectomy and thrombolysis. We report a case of extracorporeal life support (ECLS) used as salvage therapy for a critically ill pregnant patient. CASE REPORT A 21-year-old woman presented to a small rural hospital with chest pain, dyspnea, hypoxia, and syncope. In their emergency department, she suffered 2 episodes of cardiac arrest requiring cardiopulmonary resuscitation, and fetal demise followed. A computed tomography scan revealed a saddle PE. She was transferred to our tertiary care hospital and arrived critically ill, on multiple vasopressors, and in cardiogenic shock. Because standard treatments, namely thrombolysis and embolectomy, were contraindicated in this case, ECLS was employed for 7 days. She was discharged home after 23 days, and at follow-up 5 months after her admission, she was found to have made a near-complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECLS is a viable option as salvage therapy for pregnant patients with massive PE who have contraindications to thrombolysis and embolectomy.
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Martillotti G, Boehlen F, Robert-Ebadi H, Jastrow N, Righini M, Blondon M. Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review. J Thromb Haemost 2017; 15:1942-1950. [PMID: 28805341 DOI: 10.1111/jth.13802] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Indexed: 11/28/2022]
Abstract
Essentials The evidence on how to manage life-threatening pregnancy-related pulmonary embolism (PE) is scarce. We systematically reviewed all available cases of (sub)massive PE until December 2016. Thrombolysis in such severe PE was associated with a high maternal survival (94%). The major bleeding risk was much greater in the postpartum (58%) than antepartum period (18%). SUMMARY Background Massive pulmonary embolism (PE) during pregnancy or the postpartum period is a rare but dramatic event. Our aim was to systematically review the evidence to guide its management. Methods We searched Pubmed, Embase, conference proceedings and the RIETE registry for published cases of severe (submassive/massive) PE treated with thrombolysis, percutaneous or surgical thrombectomy and/or extracorporeal membrane oxygenation (ECMO), occurring during pregnancy or within 6 weeks of delivery. Main outcomes were maternal survival and major bleeding, premature delivery, and fetal survival and bleeding. Results We found 127 cases of severe PE (at least 83% massive; 23% with cardiac arrest) treated with at least one modality. Among 83 women with thrombolysis, survival was 94% (95% CI, 86-98). The risk of major bleeding was 17.5% during pregnancy and 58.3% in the postpartum period, mainly because of severe postpartum hemorrhages. Fetal deaths possibly related to PE or its treatment occurred in 12.0% of cases treated during pregnancy. Among 36 women with surgical thrombectomy, maternal survival and risk of major bleeding were 86.1% (95% CI, 71-95) and 20.0%, with fetal deaths possibly related to surgery in 20.0%. About half of severe postpartum PEs occurred within 24 h of delivery. Conclusions Published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest a high maternal and fetal survival (94% and 88%). In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter [or surgical] thrombectomy, ECMO) may be considered if available.
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Affiliation(s)
- G Martillotti
- Department of Obstetrics and Gynecology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - F Boehlen
- Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - H Robert-Ebadi
- Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - N Jastrow
- Department of Obstetrics and Gynecology, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Righini
- Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - M Blondon
- Division of Angiology and Hemostasis, Department of Specialties of Medicine, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Friedman O, Horowitz JM, Ramzy D. Advanced Cardiopulmonary Support for Pulmonary Embolism. Tech Vasc Interv Radiol 2017; 20:179-184. [PMID: 29029712 DOI: 10.1053/j.tvir.2017.07.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Management of high-risk pulmonary embolism (PE) requires an understanding of the pathophysiology of PE, options for rapid clot reduction, critical care interventions, and advanced cardiopulmonary support. PE can lead to rapid respiratory and hemodynamic collapse via a complex sequence of events leading to acute right ventricular failure. Importantly, reduction in pulmonary vascular resistance must be accomplished either by systemic thrombolytics, catheter directed thrombolytics, endovascular clot extraction, or surgical embolectomy. There are important advances in these techniques all of which have a niche role in the cardiopulmonary stabilization of critically ill patient with PE. Critical care support surrounding the above interventions is necessary. Maintenance of systemic perfusion and cardiac output may require careful titration of vasopressors, inotropes, and preload. Extreme caution should be taken with approach to intubation and positive pressure ventilation. A hemodynamically neutral induction with preparations for circulatory collapse should be the goal. Once intubated, the effect of positive pressure on pulmonary vascular resistance and right ventricular hemodynamics is necessary. Veno-arterial extra corporeal membrane oxygenation plays an increasingly important role in the stabilization of the hemodynamically collapsed patient who either has a contraindication to systemic lytics, failed systemic lytics, or requires a bridge to surgical or catheter embolectomy. Veno-arterial extra corporeal membrane oxygenation has also been used alone to stabilize the circulation until hemodynamics normalize on anticoagulation and has also been used in tenuous patient as a safety net for endovascular procedures.
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Affiliation(s)
- Oren Friedman
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - James M Horowitz
- Division of Cardiology, New York University Langone Medical Center, Los Angeles, CA
| | - Danny Ramzy
- Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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10
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Spontaneous, Postpartum Coronary Artery Dissection and Cardiogenic Shock with Extracorporeal Membrane Oxygenation Assisted Recovery in a 30-Year-Old Patient. Case Rep Cardiol 2016; 2016:1048708. [PMID: 27127660 PMCID: PMC4823494 DOI: 10.1155/2016/1048708] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 03/13/2016] [Indexed: 11/17/2022] Open
Abstract
Coronary artery dissection is an infrequent cause of acute coronary syndrome in the general population. There is, however, a greater incidence of spontaneous coronary artery dissection (SCAD) in young women, especially in the peripartum period. However, the majority of cases have favorable outcomes with medical management or percutaneous coronary intervention; coronary artery bypass grafting (CABG) and transplantation are utilized in severe cases. This case is a one of a 30-year-old postpartum female with multivessel SCAD requiring CABG with subsequent biventricular failure and inability to wean from bypass. We believe this is the first reported case in which venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used in the management of biventricular heart failure in a postpartum patient with SCAD.
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11
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Schaheen BW, Thiele RH, Isbell JM. Extracorporeal life support for adult cardiopulmonary failure. Best Pract Res Clin Anaesthesiol 2015; 29:229-39. [PMID: 26060032 DOI: 10.1016/j.bpa.2015.04.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 04/11/2015] [Accepted: 04/14/2015] [Indexed: 01/19/2023]
Abstract
The use of extracorporeal life support (ECLS) or extracorporeal membrane oxygenation (ECMO), as it is also known, has rapidly expanded over the past decade. The increase in ECMO use is a consequence of multiple factors including significant advancements in extracorporeal technology, the emergence of data supporting its use, and a growing number of potential clinical applications. This review focuses on the various modes of ECLS as well as the clinical indications and available evidence for the use of extracorporeal support.
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Affiliation(s)
- Basil W Schaheen
- General Surgery, University of Virginia, P.O. Box 800681, Charlottesville, VA 22908, USA.
| | - Robert H Thiele
- Department of Anesthesiology, University of Virginia Health System, P.O. Box 800710, Charlottesville, VA 22908-0710, USA.
| | - James M Isbell
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia Health System, P.O. Box 800679, Charlottesville, VA 22908, USA.
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13
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Chon MK, Park YH, Choi JH, Lee SH, Kim JS, Kim J, Kim JH, Chun KJ. Thrombolytic therapy complemented by ECMO: successful treatment for a case of massive pulmonary thromboembolism with hemodynamic collapse. J Korean Med Sci 2014; 29:735-8. [PMID: 24851033 PMCID: PMC4024947 DOI: 10.3346/jkms.2014.29.5.735] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 10/17/2013] [Indexed: 12/16/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.
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Affiliation(s)
- Min Ku Chon
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong Hyun Park
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jin Hee Choi
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jun Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - June Hong Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kook Jin Chun
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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14
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Saeed G, Möller M, Neuzner J, Gradaus R, Stein W, Langebrake U, Dimpfl T, Matin M, Peivandi A. Emergent surgical pulmonary embolectomy in a pregnant woman: case report and literature review. Tex Heart Inst J 2014; 41:188-94. [PMID: 24808782 DOI: 10.14503/thij-12-2692] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Acute pulmonary embolism is a leading cause of death during pregnancy and delivery in the United States. We describe the case of a 25-year-old woman who presented in cardiogenic shock in week 38 of her first pregnancy. After the emergent cesarean delivery of a healthy male neonate, the mother underwent immediate surgical pulmonary embolectomy. We confirmed the diagnosis of pulmonary embolism intraoperatively by means of transesophageal echocardiography and removed large clots from the patient's pulmonary arteries. Mother and child were doing well, 27 months later. In addition to presenting our patient's case, we discuss the other relevant reports and the options for treating massive pulmonary embolism during pregnancy.
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Affiliation(s)
- Giovanni Saeed
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Michael Möller
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Jörg Neuzner
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Rainer Gradaus
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Werner Stein
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Uwe Langebrake
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Thomas Dimpfl
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Meradjoddin Matin
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
| | - Ali Peivandi
- Departments of Cardiovascular Surgery (Drs. Matin, Peivandi, and Saeed), Internal Medicine II and Cardiology (Drs. Gradaus, Möller, and Neuzner), Gynecology and Obstetrics (Drs. Dimpfl and Stein), and Anesthesiology and Intensive Care Medicine (Dr. Langebrake), Klinikum Kassel GmbH, 34125 Kassel, Germany
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15
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Noble DW, Bloomfield R. Problem Solving in Intensive Care — The Role of Extracorporeal Technologies. J Intensive Care Soc 2014. [DOI: 10.1177/175114371401500102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- David W Noble
- Consultant in Intensive Care, Aberdeen Royal Infirmary
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16
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KUDLIČKA J, MLČEK M, HÁLA P, LACKO S, JANÁK D, HRACHOVINA M, MALÍK J, BĚLOHLÁVEK J, NEUŽIL P, KITTNAR O. Pig Model of Pulmonary Embolism: Where Is the Hemodynamic Break Point? Physiol Res 2013; 62:S173-9. [DOI: 10.33549/physiolres.932673] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Early recognition of collapsing hemodynamics in pulmonary embolism is necessary to avoid cardiac arrest using aggressive medical therapy or mechanical cardiac support. The aim of the study was to identify the maximal acute hemodynamic compensatory steady state. Overall, 40 dynamic obstructions of pulmonary artery were performed and hemodynamic data were collected. Occlusion of only left or right pulmonary artery did not lead to the hemodynamic collapse. When gradually obstructing the bifurcation, the right ventricle end-diastolic area expanded proportionally to pulmonary artery mean pressure from 11.6 (10.1, 14.1) to 17.8 (16.1, 18.8) cm2 (p<0.0001) and pulmonary artery mean pressure increased from 22 (20, 24) to 44 (41, 47) mmHg (p<0.0001) at the point of maximal hemodynamic compensatory steady state. Similarly, mean arterial pressure decreased from 96 (87, 101) to 60 (53, 78) mmHg (p<0.0001), central venous pressure increased from 4 (4, 5) to 7 (6, 8) mmHg (p<0.0001), heart rate increased from 92 (88, 97) to 147 (122, 165) /min (p<0.0001), continuous cardiac output dropped from 5.2 (4.7, 5.8) to 4.3 (3.7, 5.0) l/min (p=0.0023), modified shock index increased from 0.99 (0.81, 1.10) to 2.31 (1.99, 2.72), p<0.0001. In conclusion, instead of continuous cardiac output all of the analyzed parameters can sensitively determine the individual maximal compensatory response to obstructive shock. We assume their monitoring can be used to predict the critical phase of the hemodynamic status in routine practice.
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Affiliation(s)
- J. KUDLIČKA
- Third Department of Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
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17
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Abstract
Approximately 1% to 4% of pregnant women are evaluated in emergency/delivery room because of traumatic injury, yet there are few educational strategies targeted toward prevention/management of maternal trauma. Use of illicit drugs and alcohol, domestic abuse, and depression contribute to maternal trauma; thus a high index of suspicion should be maintained when treating injured young women. Treating the mother appropriately is beneficial for both the mother and the fetus. Fetal viability should be assessed after maternal stabilization. Pregnancy-related morbidity occurs in approximately 25% of cases and may include placental abruption, uterine rupture, preterm delivery, and the need for cesarean delivery.
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Affiliation(s)
- Sharon Einav
- Hebrew University School of Medicine, Shaare Zedek Medical Centre, Jerusalem, Israel.
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18
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Bunwaree S, Roffi M, Bonvini JM, Noble S, Righini M, Bonvini RF. AngioJet ®rheolytic thrombectomy: a new treatment option in cases of massive pulmonary embolism. Interv Cardiol 2013. [DOI: 10.2217/ica.12.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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19
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Ko CH, Forrest P, D’Souza R, Qasabian R. Successful use of extracorporeal membrane oxygenation in a patient with combined pulmonary and systemic embolisation. Perfusion 2012; 28:138-40. [DOI: 10.1177/0267659112463163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We present a highly unusual case of massive pulmonary embolism with secondary paradoxical systemic embolisation that was successfully resuscitated with veno-arterial extracorporeal membrane oxygenation (ECMO). This enabled subsequent successful bridging to pulmonary embolectomy.
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Affiliation(s)
- C-H Ko
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - P Forrest
- Cardiothoracic Anaesthesia and Perfusion. Royal Prince Alfred Hospital, Camperdown, NSW. Clinical Associate Professor, University of Sydney, Sydney, Australia
| | - R D’Souza
- Department of Anaesthesia, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - R Qasabian
- Vascular Surgery. Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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