Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism

Abstract

OBJECTIVES There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan–Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.

Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock

“…Corsi et al interviewed 7 patients at a mean follow-up of 19 months post-hospital discharge using the SF-36 and found QoL impaired compared to a sex- and age-matched control [ 13 ]. Similar findings are reported by Sertic, with patients strongly limited concerning physical, but preserved mental health [ 21 ].…”

Massive Embolism: Knife versus PCI

“…Of those patients that survived to discharge, most were discharged without sequalae from a PE, including resolution of any RV dysfunction. 43 Looking further into the impact of precannulation CPR, Sertic et al demonstrated that those patients that had return of spontaneous circulation prior to cannulation had superior short-and mid-term outcomes as well as a lower rate of cerebrovascular accidents when compared with those who were placed on ECMO while actively undergoing CPR. 43 In another study by George et al, looking at patients who required ECMO for massive PE, 65.5% survived until decannulation and 53.1% survived to discharge.…”

“…43 Looking further into the impact of precannulation CPR, Sertic et al demonstrated that those patients that had return of spontaneous circulation prior to cannulation had superior short-and mid-term outcomes as well as a lower rate of cerebrovascular accidents when compared with those who were placed on ECMO while actively undergoing CPR. 43 In another study by George et al, looking at patients who required ECMO for massive PE, 65.5% survived until decannulation and 53.1% survived to discharge. In this study, the most common causes of death were unrecoverable hemodynamic collapse, gastrointestinal bleeding, ischemic colitis, and hemorrhagic stroke.…”

“…When used concomitantly, adjunctive interventional therapies such as SPE and catheter-based interventions for ECMO patients with massive PE have been shown to have improved mortality outcomes than when only OMT is used with ECMO support. 38,43 Limitations in Use of ECMO for Massive PE Despite the promising benefit of ECMO in massive PE survival, there are important clinical presentations that limit its use in hemodynamically unstable patients. It has been seen that patients with a history of malignancy tend to have significantly higher mortality rates, with some studies demonstrating a sixfold increase in mortality compared with those patients without malignancy.…”

“…43 Looking further into the impact of precannulation CPR, Sertic et al demonstrated that those patients that had return of spontaneous circulation prior to cannulation had superior short- and mid-term outcomes as well as a lower rate of cerebrovascular accidents when compared with those who were placed on ECMO while actively undergoing CPR. 43…”