Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism as Bridge to Therapy

Abstract

Pulmonary Embolism (PE) is a common illness in western countries. The purpose of this study is to report the institutional experience with massive PE and Extracorporeal Membrane Oxygenation (ECMO) in inoperable patients on admission. A retrospective analysis using the institutional ECMO-registry including the time between 2006 and 2017 was performed. During the study period, 75 patients (n = 46 patients venoarterial [VA], n = 29 patients venovenous [VV]) were placed on ECMO for massive PE. The primary support for massive PE consists of VA; however, VV support can be applied as well in selected cases as this work demonstrates. In the VA group, more patients (38 vs. 83%, P = 0.001) required mechanical resuscitation whereas in the VV group a more aggressive ventilation before support was noted (e.g. minute ventilation: VA=8.8 ± 3.7 L/min, VV=11.5 ± 4.5 L/min, P = 0.01). Survival to discharge was similar in VV and VA patients (45 vs. 48%, P = 0.9). Patients who received additional therapeutic interventions after stabilization with ECMO – e.g. surgical thrombectomy – displayed a similar survival compared with those being only anticoagulated (44% vs. 49%, P = 0.40). ECMO is feasible for initial stabilization serving as a bridge to therapy in primarily inoperable patients with massive PE. The principal configuration of support is VA; however, VV can be applied as well in selected hemodynamically compromised cases under aggressive ventilation.

Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock

“…In some reports, survival reaches 70% with good neurological function at discharge (Table 2). Cardiac arrest prior to VA-ECMO initiation and a lactic acid level exceeding 6 mmol/L was associated with worse outcomes (112)(113)(114)(115)(116)(117) (119,120). Although relatively rare, the most severe complications include acute respiratory distress syndrome, acute coronary syndrome secondary to coronary thrombosis or microembolism and stressinduced cardiomyopathy (121)(122)(123)(124)(125)(126)(127).…”

Use of extracorporeal membrane oxygenation in high‐risk acute pulmonary embolism: A systematic review and meta‐analysis

“…Among the 421 studies identified by the search strategy, 106 studies were deemed eligible and 21 studies were eventually included in the analysis, for a total population of 635 patients with acute high‐risk PE receiving ECMO support 11‐31 . Exclusion reasons were: overlapping populations ( n = 10), studies not focused on ECMO use in PE ( n = 4), commentary papers ( n = 3), studies not reporting outcome of interest ( n = 1), and case reports/cases series including < 4 patients ( n = 67).…”

Evidence-Based Minireview: Advanced therapies and extracorporeal membrane oxygenation for the management of high-risk pulmonary embolism

“…3 Level of evidence for embolectomy is probably at the same level as for CDT and ECMO in the current era, as more studies show benefit of ECMO with heparin as a stand-alone therapy. 37 Following hemodynamic stabilization, patients recovering from high-risk PE can be switched from parenteral to oral anticoagulation. As these patients were excluded from the direct acting oral anticoagulant clinical trials, the optimal time point for this transition and their efficacy has not been determined by existing evidence.…”