Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

Abstract

Background: Despite 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.

Methods: ECMO-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.

Results: Seventeen 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.

Conclusions: VA-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.

Keywords: Cardiogenic shock; Extracorporeal membrane oxygenation; Long-term quality of life; Massive pulmonary embolism.

Fig. 1

Study flow chart. CPR cardiopulmonary resuscitation, HRQOL health- related quality of life, PE pulmonary embolism, VA-ECMO venoarterial-extracorporeal membrane oxygenation

Fig. 2

Box plots of the inotrope score change between pre- and post-VA-ECMO cannulation according to patients’ 90-day status. Bold horizontal lines are medians; lower and upper box limits are 25th–75th percentiles; T-bars represent 10th–90th percentiles. ECMO extracorporeal membrane oxygenation

Fig. 3

Comparison of median Short Form-36 scores of our high-risk massive PE survivors treated with VA-ECMO after median 19-month follow-up post-hospital discharge and their age- and sex-matched control subjects [18], 67 venovenous-ECMO-treated acute respiratory distress syndrome (ARDS) survivors at 17-month follow-up [23] and ten VA-ECMO-treated septic shock patients [23]. Higher scores denote better health-related quality of life. ECMO extracorporeal membrane oxygenation, ARDS acute respiratory disease syndrome, PF physical functioning, RP role-physical, BP body pain, GH general health, VT vitality, SF social functioning, RE role-emotional, MH mental health, PCS physical component score, MCS mental component score