ECPR for cardiac arrest caused by postoperative massive pulmonary embolism in a super-morbidly obese patient: A case report

Abstract

Background: Massive pulmonary embolism (PE) remains a leading cause of preventable perioperative mortality after bariatric surgery. Cardiopulmonary resuscitation (CPR) is challenging in patients with extreme obesity, and extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used as a salvage therapy. Case Presentation: A 60-year-old woman with super-super obesity (body weight: 142 kg; body mass index [BMI]: 61 kg/m2) suffered pulseless electrical activity (PEA) cardiac arrest on postoperative day (POD) 3 following elective robotic Roux-en-Y gastric bypass. Management: ECPR was initiated using veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Cannulation was difficult due to her extreme body habitus, resulting in a prolonged low-flow time of 85 minutes to reach target flow. Bedside echocardiography and pulmonary artery catheterization confirmed massive obstructive shock. Thrombolysis was deferred due to bleeding risks from the fresh bariatric incision, and she was successfully managed with conservative anticoagulation. Her ICU course was complicated by new-onset atrial fibrillation, septic shock, and Harlequin syndrome, all of which were successfully resolved. Outcome: Although cardiopulmonary function recovered and follow-up computed tomographic pulmonary angiography showed complete thrombus resolution, she sustained severe hypoxic–ischemic encephalopathy (HIE) and died one year later. Conclusion: Standardized adherence to combined mechanical and pharmacologic venous thromboembolism (VTE) prophylaxis is essential in patients with super-super obesity. While ECPR can restore systemic circulation, technical challenges can prolong low-flow time and compromise neurological outcomes.