IMR Press / RCM / Volume 23 / Issue 6 / DOI: 10.31083/j.rcm2306193
Open Access Original Research
Venoarterial Extracorporeal Membrane Oxygenation in High-Risk Pulmonary Embolism: A Case Series and Literature Review
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1 Service of Adult Intensive Care Medicine, Lausanne University Hospital, 1010 Lausanne, Switzerland
2 Service of Anesthesiology, Lausanne University Hospital, 1010 Lausanne, Switzerland
3 Service of Radiology, Lausanne University Hospital, 1010 Lausanne, Switzerland
4 Service of Cardiac Surgery, Lausanne University Hospital, 1010 Lausanne, Switzerland
*Correspondence: zied.ltaief@chuv.ch (Zied Ltaief)
These authors contributed equally.
Academic Editors: Karim Bendjelid and Raphael Giraud
Rev. Cardiovasc. Med. 2022, 23(6), 193; https://doi.org/10.31083/j.rcm2306193
Submitted: 11 February 2022 | Revised: 14 April 2022 | Accepted: 28 April 2022 | Published: 27 May 2022
(This article belongs to the Special Issue Cardiogenic Shock)
Copyright: © 2022 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.
Abstract

Background: High-risk Pulmonary Embolism (PE) has an ominous prognosis and requires emergent reperfusion therapy, primarily systemic thrombolysis (ST). In deteriorating patients or with contraindications to ST, Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) may be life-saving, as supported by several retrospective studies. However, due to the heterogeneous clinical presentation (refractory shock, resuscitated cardiac arrest (CA) or refractory CA), the real impact of VA-ECMO in high-risk PE remains to be fully determined. In this study, we present our centre experience with VA-ECMO for high-risk PE. Method: From 2008 to 2020, we analyzed all consecutive patients treated with VA-ECMO for high-risk PE in our tertiary 35-bed intensive care unit (ICU). Demographic variables, types of reperfusion therapies, indications for VA-ECMO (refractory shock or refractory CA requiring extra-corporeal cardiopulmonary resuscitation, ECPR), hemodynamic variables, initial arterial blood lactate and ICU complications were recorded. The primary outcome was ICU survival, and secondary outcome was hospital survival. Results: Our cohort included 18 patients (9F/9M, median age 57 years old). VA-ECMO was indicated for refractory shock in 7 patients (2 primary and 5 following resuscitated CA) and for refractory CA in 11 patients. Eight patients received anticoagulation only, 9 received ST, and 4 underwent surgical embolectomy. ICU survival was 1/11 (9%) for ECPR vs 3/7 (42%) in patients with refractory shock (p = 0.03, log-rank test). Hospital survival was 0/11 (0%) for ECPR vs 3/7 for refractory shock (p = 0.01, log-rank test). Survivors and Non-survivors had comparable demographic and hemodynamic variables, pulmonary obstruction index, and amounts of administered vasoactive drugs. Pre-ECMO lactate was significantly higher in non-survivors. Massive bleeding was the most frequent complication in survivors and non-survivors, and was the direct cause of death in 3 patients, all treated with ST. Conclusions: VA-ECMO for high-risk PE has very different outcomes depending on the clinical context. Furthermore, VA-ECMO was associated with significant bleeding complications, with more severe consequences following systemic thrombolysis. Future studies on VA-ECMO for high-risk PE should therefore take into account the distinct clinical presentations and should determine the best strategy for reperfusion in such circumstances.

Keywords
pulmonary embolism
cardiac arrest
obstructive cardiogenic shock
cardiopulmonary resuscitation
extra-corporeal cardiopulmonary resuscitation (ECPR)
veno-arterial extra-corporeal membrane oxygenation (VA-ECMO)
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