Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases

Abstract

Background: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE.

Methods: Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated.

Results: Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001).

Conclusions: ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.

Keywords: Acute pulmonary embolism; Cardiac arrest; Cardiopulmonary resuscitation; Extracorporeal membrane oxygenation.

Fig. 1

Study flow chart before ECMO support. LMWH, low-molecular-weight heparin; PE, pulmonary embolism; UFH, unfractionated heparin; ECMO, veno-arterial extracorporeal membrane oxygenation

Fig. 2

Flow chart describing therapeutic strategy and survival after ECMO support. PE, pulmonary embolism; ECMO, veno-arterial extracorporeal membrane oxygenation

Fig. 3

Relationships between the CT values and the time interval from CT exam to CPR or ECMO placement. CPR, cardiopulmonary resuscitation; CT, computed tomography; ECMO, veno-arterial extracorporeal membrane oxygenation; RV/LV, right-to-left ventricular