Case Presentation: A 46-year-old man with no prior medical history, with family history of Factor V Leiden mutation in father presented with a one-week history of progressive dyspnea, fatigue, and weakness. Initial imaging at an outside facility revealed bilateral pulmonary emboli with a saddle embolus, left lower lobe infarction, and right heart strain. He was started on intravenous heparin and transferred for advanced cardiac care. Thrombolytic therapy with tenecteplase was administered for massive pulmonary embolism with right ventricular failure. Overnight, he developed hypotension, diaphoresis and desaturated to 88% spo2 requiring rapid response intervention; subsequently, he sustained a cardiac arrest with return of spontaneous circulation after four cycles of CPR. He was initiated on vasopressor support and mechanical ventilation. Bedside echocardiography confirmed severe right ventricular systolic dysfunction and acute cor pulmonale. During this time he developed transient acute kidney injury, ischemic hepatitis in the setting of cardiac arrest.Rescue mechanical thrombectomy with right ventricular Impella support was performed on the same day. Levophed requirement was decreased and oxygenation improved on day two. On day two, RV Impella was removed and the patient was off pressors by day three. He was successfully weaned off mechanical ventilation by the end of one week.Therapeutic anticoagulation was transitioned from heparin to apixaban, then rivaroxaban for long-term management. Coreg was initiated for sinus tachycardia. The patient was discharged hemodynamically stable with recommendations for close outpatient follow-up with primary care and cardiology. This case highlights the importance of rapid recognition and aggressive management with RV Impella for massive pulmonary embolism complicated by obstructive shock with right heart failure.
Discussion: The Impella RP is a percutaneous, microaxial RV assist device capable of delivering up to 4 L/min of flow, approved for acute RV failure refractory to medical therapy.[2][4][6] In the context of massive PE, the device can partially decompress the RV and augment cardiac output, potentially reversing shock and facilitating recovery.[1][3][7][8] Case reports and small series have demonstrated successful hemodynamic stabilization and RV recovery in patients with massive PE and profound shock, with rapid reduction in vasopressor requirements and improvement in RV function following Impella RP implantation.[3][7][8][6] Compared to venoarterial extracorporeal membrane oxygenation (VA-ECMO), which unloads both RV preload and afterload and improves oxygenation, Impella RP offers selective RV support but may be less effective in cases of severe pulmonary vascular obstruction.[1][5][10]
Conclusions: In patients with massive PE and refractory RV failure, Impella RP may provide rapid hemodynamic stabilization and bridge to definitive therapy, but its use should be individualized, considering anatomical and physiological constraints. While promising, further prospective studies are needed to clarify its safety, efficacy, and optimal role relative to other MCS modalities in this high-risk population.[1][2][3][9][4][5][8][6]