Venoarterial extracorporeal membrane oxygenation is an effective management strategy for massive pulmonary embolism patients

Guliani, Sundeep; Gupta, Jaideep Das; Osofsky, Robin; Kraai, Erik; Mitchell, Jessica; Dettmer, Todd; Wray, Trenton; Tawil, Isaac; Rana, Muhammad Ali; Marinaro, Jonathan

doi:10.1016/j.jvsv.2020.04.033

Cited by 27 publications

(36 citation statements)

References 25 publications

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“…There are several aetiologies of heart failure that are bearable with VA-ECMO. These can be broadly classified into severe and refractory forms of cardiogenic shock [ 4 ], cardiac arrest [ 5 ], refractory ventricular arrhythmias [ 6 ], acute myocarditis [ 7 ] and acute or decompensated right ventricular (RV) heart failure (as with MAPE) [ 8 , 9 , 10 , 11 , 12 ]. In MAPE, case series and cohort studies have reported that ECMO has been used as a replacement, as a complement or as a rescue technique serving as a bridge to reperfusion therapy.…”

Section: Introductionmentioning

confidence: 99%

Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism?

Giraud

Laurencet

Assouline

et al. 2021

JCM

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Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p < 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.

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Section: Introductionmentioning

confidence: 99%

Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism?

Giraud

Laurencet

Assouline

et al. 2021

JCM

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“…Other noteworthy findings were that patients with massive PE who received VA-ECMO and PMT had satisfying outcomes from this combined management approach and that some survivors required ECMO and PMT combined therapy. Thus, based on the increased number of case reports and current practice in many centers, guidelines should evolve to consider ECMO as first-line therapy in patients with massive PE in whom classical thrombolytic therapies are restricted (1,10,28). The significant success we achieved following the initiation of VA-ECMO in our patients was related to the implementation of this policy at our institution.…”

Section: Results In Contextmentioning

confidence: 98%

“…Acute massive pulmonary embolism (PE) remains one of the most common life-threatening diseases. It is characterized by sustained hypotension (systolic blood pressure <90 mm Hg for >15 min or requiring inotropic support), pulselessness, or persistent profound bradycardia (1). Although accounting for only 5% of all PEs, massive PEs are accompanied by mortality rates ranging from 25 to 60% (2).…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal Membrane Oxygenation—First Strategy for Acute Life-Threatening Pulmonary Embolism

Liu

Chen

et al. 2022

Front. Cardiovasc. Med.

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BackgroundBoth venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm.MethodsThis study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021.ResultsMean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively.ConclusionsAn ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy.Type of ResearchSingle-center retrospective review of a prospectively maintained registry.

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“…65 In select PE scenarios, the use of VA-ECMO and CDT in combination appears to be beneficial in terms of providing needed circulatory support while simultaneously treating the underlying pathophysiology. 66 Based on available series and reports, these combined interventions appear safe, associated with few complications, and may enable an optimal means in which to enable RV recovery after massive PE. However, until further investigation occurs on the use of this combined modality, it remains unclear in which exact patients and in which PE scenarios that combined ECMO, and CDT therapies should be the treatment of choice.…”

Section: Role Of Veno-arterial Ecmo In the Management Of Acute Pementioning

confidence: 99%