Heparin and Venoarterial Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism Management: A Case Report.

BACKGROUND The aging population and rising prevalence of chronic diseases have led to a continued increase in the global burden of pulmonary embolism, while the presence of complex cases requiring individualized management poses challenges for clinicians in establishing clear diagnostic and therapeutic pathways. CASE REPORT A 61-year-old woman with high-risk pulmonary embolism was initially misdiagnosed with acute coronary syndrome and treated with oral loading doses of dual antiplatelet therapy (DAPT). After unfractionated heparin anticoagulation, her condition deteriorated, and rescue systemic thrombolysis failed. Upon multidisciplinary consultation, interventional thrombectomy under venoarterial extracorporeal membrane oxygenation (VA-ECMO) support was attempted. During the operation, a large, smooth embolus was unexpectedly observed spanning both the left and right main pulmonary arteries. It could not be extracted via suction catheter. Following imaging to rule out tumor embolism, her condition gradually improved with continued heparin anticoagulation under ECMO support. CONCLUSIONS This case indicates that early VA-ECMO support, when paired with heparin anticoagulation in high-risk pulmonary embolism patients who have an elevated bleeding risk or are expected to fail conventional reperfusion therapy, may facilitate stable thrombus dissolution, enhance the advantages of ECMO support, and ultimately improve rescue success rates. Nevertheless, the single-case nature and lack of comparative evidence render these conclusions strictly hypothesis-generating, with no implication of generalizability. Therefore, future studies are warranted to further delineate the appropriate patient population and the optimal timing for implementing this strategy.