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Review
. 2022 Aug 13;11(16):4734.
doi: 10.3390/jcm11164734.

Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation?

Benjamin Assouline  1 , Marie Assouline-Reinmann  2 , Raphaël Giraud  3   4 , David Levy  1 , Ouriel Saura  1 , Karim Bendjelid  3   4 , Alain Combes  1   5 , Matthieu Schmidt  1   5
Affiliations
Review

Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation?

Benjamin Assouline et al. J Clin Med. .

Abstract

Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39-115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.

Keywords: ECPR; VA-ECMO; high-risk pulmonary embolism; massive pulmonary embolism; reperfusion therapy.

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Conflict of interest statement

A.C. has received grants from Getinge, and personal fees from Getinge, Baxter, and Xenios outside the submitted work. M.S. has received personal fees from Getinge, Drager, and Xenios, outside the submitted work.

Figures

Figure 1
Figure 1
Percentage of patients cannulated during CPR/immediately after cardiac arrest or in cardiogenic shock in the main studies on VA-ECMO use in high-risk PE. E-CPR, Extracorporeal cardiopulmonary resuscitation; PE, pulmonary embolism; VA ECMO, venoarterial extracorporeal membrane oxygenation [7,9,10,11,19,37,39,40,41,42,43,44,45,46,47,48,49,50].
Figure 2
Figure 2
Proposal algorithm for care management of high-risk pulmonary embolism. RV, right ventricle; PE, pulmonary embolism; VA ECMO, venoarterial extracorporeal membrane oxygenation.
See this image and copyright information in PMC

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