Abstract
BackgroundDespite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.MethodsECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.ResultsSeventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge.ConclusionsVA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.
Highlights
Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable
The epidemiology of massive PE is difficult to determine, it remains a significant cause of cardiovascular morbidity and mortality worldwide, with overall in-hospital mortality rates ranging from 25% for patients with cardiogenic shock to 65% for those requiring cardiopulmonary resuscitation [1, 2]
Peripheral Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) was implanted for refractory cardiogenic shock several hours post-surgical embolectomy for one patient, whereas another was cannulated during the procedure in the operating room (RA–pulmonary artery (PA) central configuration)
Summary
Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation. Massive high-risk pulmonary embolism (PE) is defined as an embolus sufficiently obstructing pulmonary blood flow to cause right ventricular (RV) failure, hypoxemia, and hemodynamic instability [1]. Because of contraindications or major clinical instability, a few patients are not amenable to reperfusion therapies or fail to improve after this treatment. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is one of the most reliable and quickest ways to decrease RV overload, improve RV function and hemodynamic status, and restore tissue oxygenation. We describe our tertiary-care center’s experience with VA-ECMO– treated patients with acute, massive, high-risk PE, and report their short- and long-term outcomes
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