Case Report

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

^* Division of Pediatric Critical Care, Department of Pediatrics, ^‡ Division of Pediatric Hematology and Oncology, Department of Pediatrics, ^§ Division of Vascular and Interventional Radiology, Department of Radiology, ^‖ Department of Cardiothoracic Surgery, and ^¶ Subdivision of Pulmonology and Advance Lung Failure, Department of Internal Medicine, University of Florida, Gainesville, Florida
^† Division of Pediatric Cardiac Critical Care, Department of Pediatrics, Congenital Heart Center,University of Florida, Gainesville, Florida

Address correspondence to: Desiree S. Machado, MD, University of Florida, 1600 Archer Road, Gainesville, FL 32608. E-mail: desireemachado@ufl.edu

Received: 3 March 2020
Accepted: 3 September 2020

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.