Extra-corporeal membrane oxygenation and outcomes in massive pulmonary embolism: Two eras at an urban tertiary care hospital

Abstract

Mortality associated with high-risk pulmonary embolism (PE) remains high. Extra-corporeal membrane oxygenation (ECMO) allows for acute hemodynamic stabilization and potentially for administration of other disease process altering therapies. We sought to compare two eras: pre-ECMO and post-ECMO in relation to high-risk PE treatment and mortality. A single-center retrospective chart review was conducted of high-risk PE patients. High-risk PE was defined as acute PE and cardiac arrest or shock. A total of 60 patients were identified, 31 in the pre-ECMO era and 29 in the post-ECMO era. Mean age was 56.1±21.1 years and 51.7% were women. More patients in the post-ECMO era were identified with computed tomography (82.8% vs 51.6%, p=0.011) and more patients in the post-ECMO era had right ventricular dysfunction on echocardiography (96.4% vs 78.3%, p=0.045). No other differences were noted in baseline characteristics or clinical, laboratory and imaging data between the two groups. In total, ECMO was used in 13 (44.8%) patients in the post-ECMO era. There was greater utilization of catheter-directed therapies in the post-ECMO era compared to the pre-ECMO era ( n = 7 (24.1%) vs n = 1 (3.2%), p=0.024). Thirty-day survival increased from 17.2% in patients who presented in the pre-ECMO era to 41.4% in the post-ECMO era ( p=0.043). While more work is necessary to better identify those PE patients who stand to benefit from mechanical circulatory support, our findings have important implications for the management of such patients.

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up

“…Indiscriminate use of inferior vena cava filters should be avoided (93). Recurrent PE despite optimal anticoagulation, or clinically-significant VTE in the setting of absolute contraindications to anticoagulation would be among the few scenarios in which placement of an inferior vena cava filter may be considered (11 bedside initiation of extracorporeal membrane oxygenation (ECMO) is preferred in cases with known COVID-19 positivity or uncertain status, rather than support strategies requiring the use of a catheterization laboratory or an operating room (95). Figure 2 presents a potential algorithm for treatments based on risk due to VTE and COVID-19 severity.…”

Venous Thromboembolism in COVID-19: Are Women Different?

“…Bedside extracorporeal membrane oxygenation (ECMO) might be considered in COVID-19 positive patients rather than utilization of interventional modalities needing cardiac catheterization laboratories or operating rooms. 13 The use of inferior vena cava (IVC) filters should be minimized to cases with recurrent PE in spite of adequate anticoagulation or in those with absolute contraindication to anticoagulation.…”

Consensus Scientific Statement on Advisory Working Guidelines and Recommendations for the Female Population in COVID-19 Era by WINCARS

“…Hence just as in males, LMWH may be preferred over unfractionated heparin (UFH) in COVID-19-positive females. 35 This is graded as class-II, level-C recommendation with available information.…”

“…Bedside extra corporeal membrane oxygenator (ECMO) might be considered in COVID-19-positive patients rather than the utilization of interventional modalities needing cardiac catheterization laboratories or operating rooms. 35 This is graded as class-II, level-C recommendation with available information.…”