A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support

George, Bennet; Parazino, Marc; Omar, Hesham R.; Davis, George A.; Guglin, Maya; Gurley, John C.; Smyth, Susan S.

doi:10.1016/j.resuscitation.2017.11.034

Cited by 77 publications

(75 citation statements)

References 16 publications

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“…Patients experiencing cardiac arrest had a poor outcome. Two large recent series (8,16) reported that the survival rate of ECMO for massive PE is 76-100% for patients with refractory cardiogenic shock and 13-27% for those that required CPR prior to ECMO placement, which is similar to our result (90% versus 18%). There is no doubt that patients presenting in cardiac arrest are associated with worse outcomes.…”

Section: Discussionsupporting

confidence: 90%

“…For critically ill patients, veno-arterial extracorporeal membrane oxygenation (ECMO) is a reliable mechanical circulatory support device to decrease right ventricular (RV) volume overload, stabilize hemodynamic status, and provide gas exchange (6), and may be considered as either a bridge to de nitive reperfusion therapy or as a stand-alone treatment strategy (7). However, evidence for use of ECMO is limited to small case series (6)(7)(8) and the role of ECMO is not established.…”

Section: Introductionmentioning

confidence: 99%

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Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases

Chen

Yen

et al. 2020

Preprint

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Background Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. Methods Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. Results Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 hours after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in 10 patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). Conclusions ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.

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Section: Discussionsupporting

confidence: 90%

Section: Introductionmentioning

confidence: 99%

Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases

Chen

Yen

et al. 2020

Preprint

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“…In the latter registry, data on outcome are limited to observational studies and vary significantly depending on underlying indication. Outcome seems to be most beneficial in patients requiring VA-ECMO support for either acute severe myocarditis, pulmonary embolism with RV failure, or primary graft failure after cardiac transplant, with reported survival rates at hospital discharge of up to 80% [10][11][12][13]. Survival to discharge rate in patients undergoing VA-ECMO and percutaneous coronary intervention in cardiogenic shock complicating acute myocardial infarction is reported to be up to 70% [14,15].…”

Section: Introductionmentioning

confidence: 99%

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

Lüsebrink

Stremmel

Stark

et al. 2020

JCM

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Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.

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A protocolized approach to veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism

Sir,We recently read with interest the manuscript by George and colleagues describing their experience with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for massive pulmonary embolism (PE) [1]. The authors describe their experience over a 4-year period in 32 patients.

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mentioning

confidence: 99%

A protocolized approach to veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism

Pasrija

Kon

2018

Resuscitation

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A protocolized approach to veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism Sir,We recently read with interest the manuscript by George and colleagues describing their experience with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for massive pulmonary embolism (PE) [1]. The authors describe their experience over a 4-year period in 32 patients. There was a 53% survival to discharge, and a lactic acid level < 6 mmol/L was predictive of survival. Based on the results of this study, the authors felt that there were 3 groups who may not benefit from VA-ECMO: patients with 1) malignancy, 2) pre-cannulation cardiac arrest, and 3) lactate ≥6 mmol/L.Consistent with George et al., several published series of VA-ECMO for massive PE have described a mortality rate between 40 and 60% [2][3][4]. The authors of this study are to be commended for their large experience over just a 4-year period. However, similar to the other published series, the authors do not describe a specific protocol or criteria for placement, management, or decannulation of VA-ECMO. We recently reviewed our outcomes, after establishing a protocolized approach to massive PE [5]. Over a 3-year period, we placed 20 consecutive patients on VA-ECMO as the primary planned intervention for any patient with a massive PE with end-organ dysfunction or an unclear neurologic status. There was a 95% survival to discharge and 90 days, with the 1 death in a patient who required > 60 min of cardiopulmonary resuscitation prior to ECMO consultation. In fact, 10 (50%) patients had a lactate > 6 mmol/L with a 90% survival in this subset, and 5 (25%) patients had a pre-cannulation cardiac arrest with an 80% survival in this subset. While we limit placement on VA-ECMO to patients with a predicted survival, independent of the PE, greater than 1 year, we do not believe that malignancy, cardiac arrest, or lactate level are exclusion criteria for VA-ECMO. This population of patients represents an extreme risk group, and as has been established, survival is likely to be between 40 and 60% when placing patients on VA-ECMO without a prescribed approach to cannulation, management, post-cannulation intervention, and decannulation. However, with the introduction of a protocolized approach, we have improved our own survival for massive PE more than 20%. Moreover, anticoagulation alone while on VA-ECMO resulted in normalization of right ventricular function in 40% of patients.We, therefore, believe that outcomes may dramatically improve by utilizing VA-ECMO as the primary planned intervention for patients with a massive PE and end-organ dysfunction or an unclear neurologic status.Resuscitation 126 (2018) e12 0300-9572/

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A retrospective comparison of survivors and non-survivors of massive pulmonary embolism receiving veno-arterial extracorporeal membrane oxygenation support

Cited by 77 publications

References 16 publications

Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases

Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation

A protocolized approach to veno-arterial extracorporeal membrane oxygenation for massive pulmonary embolism

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