Abstract
Introduction: Extracorporeal membrane oxygenation (ECMO) offers potentially life-saving circulatory support in patients with high-risk pulmonary embolism (PE) and refractory hemodynamic instability. Optimal reperfusion strategies in combination are unclear. Hypothesis: To investigate the contemporary use of ECMO in conjunction with reperfusion strategies in high-risk PE. Methods: We identified high-risk PE hospitalizations in the Nationwide Inpatient Sample (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Results: Among 122,735 hospitalizations for high-risk PE ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, with thrombolysis-based reperfusion in 0.4%, and with mechanical reperfusion in 0.5%. Compared to neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted OR, 0.60; 95% CI, 0.38-0.97), whereas no difference was found with ECMO plus mechanical reperfusion (1.02; 0.66-1.59), and ECMO stand-alone was associated with increased in-hospital mortality (1.59; 1.21-2.09). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (0.71; 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (0.54; 0.32-0.90), and mechanical reperfusion showed a trend (0.74; 0.47-1.18) towards reduced in-hospital mortality compared to no reperfusion, without increases in major bleeding. Conclusions: In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as stand-alone treatment especially for patients suffering from cardiac arrest.
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