Time trends and urban-rural differences in the use and outcomes of extracorporeal membrane oxygenation in patients with pulmonary embolism

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Background Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). Purpose We sought to determine time trends and urban-rural differences in the use and outcomes of ECMO in patients with acute PE. Methods We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) and ECMO implantation in Germany between 2005 and 2018. Results At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Over the 14-year observational study period the use of ECMO in patients with PE increased continuously (β 2.9 [2.7 to 3.1]; p<0.001), while in-hospital mortality decreased (ß -0.7 [-0.7 to -0.8]; p<0.001). VA-ECMO was mainly employed in younger patients (55 vs. 72 years, p<0.001). Male patients were considerably more often treated with ECMO than female patients (61.8% vs 38.2%; P<0.001) although the proportion of female patients and ECMO increased during the observation period. In patients with cardiac arrest the proportion of VA-ECMO use was highest in the second life decade (7.5%) and decreased with increasing age. As expected, the use of VA-ECMO support was strikingly more used in urban (n=1069) and suburban (n=733) areas compared to rural regions (n=219) of Germany (hier auch % angeben). In-hospital mortality was considerably lower in urban (60.6%) and suburban areas (58.8%) compared to rural regions (65.3%) (Figure 1). Conclusion The marked increase in the number of PE patients treated with ECMO during a 14-year observational period points to both improved resource availability/allocation as well as an improvement in the invasive management of PE patients at high risk in the ICU. The observation of a lower in-hospital mortality in (sub-)urban areas are in particular interesting in a densely populated country like Germany and may indicate that offering maximal level of care in (sub-)urban areas in patients with PE may lead to a better prognosis.