Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy

Abstract

Introduction Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. Methods We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. Results Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5–35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). Conclusions Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.

Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis

“…Of 2318 references screened, we sought the full text for 370 potentially relevant publications. Some 351 full-text articles were available, from which we included 39 observational studies totalling 1,177,998 patients (6409 ECMO and 1,171,589 non-ECMO) in the meta-analysis ( Figure 1 , Table S4 ) [ 9 , 10 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ], of which 13 were cohort studies and 26 were case series. There were 14 studies from Europe, 14 from Asia, and 11 from North America.…”

“…Secondly, w restricted the analysis to studies reporting on only VA-ECMO-the mortality rate also re mained relatively unchanged (41.1%, 95%-CI: 35.0% to 47.5%). [29,31,37,38,40,41,46,48,58,60,62].…”

“… Pooled risk ratio comparing patients receiving ECMO vs. no ECMO for high-risk pulmonary embolism [ 29 , 31 , 37 , 38 , 40 , 41 , 46 , 48 , 58 , 60 , 62 ]. …”

“… Subgroup analysis of mortality for patients receiving extracorporeal membrane oxygenation alone compared to ECMO with catheter-directed therapies (CDT), surgical embolectomy (SE), or systemic thrombolysis (ST) for pulmonary embolism [ 9 , 10 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 ]. …”