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Bivalirudin and Venoarterial Extracorporeal Membrane Oxygenation for Treatment of Massive Pulmonary Embolism From Heparin-Induced Thrombocytopenia With Thrombosis

Published:November 04, 2022DOI:https://doi.org/10.1053/j.jvca.2022.11.004
      HIGH-RISK OR MASSIVE pulmonary embolism (PE) is defined as acute PE with clinical presentations of cardiac arrest, acute respiratory failure, obstructive shock requiring ionotropic therapy, or sustained hypotension for >15 minutes.
      • Tapson VF
      • Weinberg AS.
      Overview of management of intermediate- and high-risk pulmonary embolism.
      Treatments for massive PE include the initiation of a PE response team (PERT), anticoagulation, systemic thrombolysis, and catheter-directed or surgical embolectomy.
      • Tapson VF
      • Weinberg AS.
      Overview of management of intermediate- and high-risk pulmonary embolism.
      Although there are mixed data supporting its superiority over other therapies, studies have shown that extracorporeal membrane oxygenation (ECMO) is another salvage therapy that can be used to support a subset of patients with respiratory and circulatory collapse despite therapeutic treatments.
      • Al-Bawardy R
      • Rosenfield K
      • Borges J
      • et al.
      Extracorporeal membrane oxygenation in acute massive pulmonary embolism: A case series and review of the literature.
      • Baldetti L
      • Beneduce A
      • Cianfanelli L
      • et al.
      Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism: A systematic review and meta-analysis.
      • Guliani S
      • Das Gupta J
      • Osofsky R
      • et al.
      Venoarterial extracorporeal membrane oxygenation is an effeive management strategy for massive pulmonary embolism patients.
      • O'Malley TJ
      • Choi JH
      • Maynes EJ
      • et al.
      Outcomes of extracorporeal life support for the treatment of acute massive pulmonary embolism: A systematic review.
      • Yusuff HO
      • Zochios V
      • Vuylsteke A.
      Extracorporeal membrane oxygenation in acute massive pulmonary embolism: A systematic review.
      • George B
      • Parazino M
      • Omar HR
      • et al.
      A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support.
      • Karami M
      • Mandigers L
      • Miranda DDR
      • et al.
      Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis.
      Heparin-induced thrombocytopenia with thrombosis (HITT) is an immune-mediated thrombocytopenia in which autoantibodies to platelet factor 4-heparin complexes result in platelet activation. This activation of platelets can lead to thrombosis and consumptive thrombocytopenia.
      • Datta P
      • Zhang F
      • Dordick JS
      • et al.
      Platelet factor 4 polyanion immune complexes: Heparin induced thrombocytopenia and vaccine-induced immune thrombotic thrombocytopenia.
      HITT can cause a variety of thrombotic events, including PE, and its management includes nonheparin anticoagulation.

      Key Words

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