Use of mechanical pulmonary reperfusion and fibrinolysis in acute massive pulmonary embolism requiring extracorporeal membrane oxygenation support: A systematic review and meta-analysis

Abstract

The optimal pulmonary revascularization strategy in acute massive pulmonary embolism (PE) requiring the implantation extra corporeal membrane oxygenation remains controversial, and data are sparse. We conducted a systematic review and meta-analysis of available evidence regarding the use of mechanical reperfusion (i.e. surgical or catheter-based embolectomy) and fibrinolytic strategies (i.e. systemic fibrinolysis, catheter-directed fibrinolysis, or as stand-alone therapy) in terms of mortality and bleeding outcomes. The literature search identified 835 studies, 17 of which were included or a total of 321 PE patients with ECMO. In total, 31.1% were treated with mechanical pulmonary reperfusion, while 78.9% received fibrinolytic strategies. The mortality rate was 23.0% in the mechanical reperfusion group and 43.1% in the fibrinolysis group ( Fig. 1 ). The pooled OR for mortality with mechanical reperfusion was 0.46 (95% CI: 0.213–0.997; I2 = 28.3%) versus fibrinolysis. The rate of bleeding in PE patients under ECMO was 29.1% in the mechanical reperfusion group and 26.0% in the fibrinolytic reperfusion (OR: 1.09; 95% CI: 0.46–2.54; I2, 0.0%) among 10 eligible studies with available bleeding data. The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy” and “ECMO implantation before pulmonary reperfusion therapy”, and outcomes. The results of the present meta-analysis and meta-regression suggest that surgical embolectomy yields the best results, regardless of the timing of VA-ECMO implantation in the reperfusion timeline, and regardless of whether fibrinolysis has been administered or not.