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Review
. 2025 Jan 7;14(1):e036101.
doi: 10.1161/JAHA.124.036101. Epub 2024 Dec 24.

Mechanical Circulatory Support for Massive Pulmonary Embolism

Salman Abdulaziz MBBS  1 , Vivek Kakar  2 , Praveen G Kumar  2 , Ibrahim Fawzy Hassan  3 , Alain Combes  4 , Daniel Brodie  5 , Nicholas A Barrett  6 , Jack Tan  7 , Saleh Fares Al Ali  1
Affiliations
Review

Mechanical Circulatory Support for Massive Pulmonary Embolism

Salman Abdulaziz MBBS et al. J Am Heart Assoc. .

Abstract

Up to 50% of patients with pulmonary embolism (PE) experience hemodynamic instability and approximately 70% of patients who die of PE experience an accelerated cascade of symptoms within the first hours of onset of symptoms, thus necessitating rapid evaluation and intervention. Venoarterial extracorporeal membrane oxygenation and other ventricular assist devices, depending on the hemodynamic derangements present, may be used to stabilize patients with massive PE refractory to initial therapies or with contraindications to other interventions. Given the abnormalities in both pulmonary circulation and gas exchange caused by massive PE, venoarterial extracorporeal membrane oxygenation may be considered the preferred form of mechanical circulatory support for most patients. Venoarterial extracorporeal membrane oxygenation unloads the right ventricle and improves oxygenation, which may not only help buy time until definitive treatment but may also reduce myocardial ischemia and myocardial dysfunction. This review summarizes the available clinical data on the use of mechanical circulatory support, especially venoarterial extracorporeal membrane oxygenation, in the treatment of patients with massive PE. Furthermore, this review also provides practical guidance on the implementation of this strategy in clinical practice.

Keywords: extracorporeal membrane oxygenation; intensive care; mechanical circulatory support; pulmonary embolism.

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Conflict of interest statement

Alain Combes reports grants from Getinge, and personal fees from Getinge, Baxter, and Xenios outside the submitted work. He is also an editor for Intensive Care Medicine. Daniel Brodie consults for LivaNova. He has been on the medical advisory boards for Medtronic, Inspira, Cellenkos, and HBOX Therapies. He is the president‐elect of the Extracorporeal Life Support Organization and the chair of the board of the International ECMO Network, and he writes for UpToDate. Jack Tan reports honoraria from AstraZeneca, Bayer, Amgen, Medtronic, Abbott Vascular, Biosensors, Alvimedica, Boehringer Ingelheim, and Pfizer; research and educational grants from Medtronic, Biosensors, Biotronik, Philips, Amgen, AstraZeneca, Roche, Otsuka, Terumo, and Abbott Vascular; and consulting fees from Elixir, CSL Behring, and Radcliffe Publishing. The remaining authors have no disclosures to report.

Figures

Figure 1
Figure 1. Pathophysiology of massive PE.
LV indicates left ventricular; PA, pulmonary artery; PE, pulmonary embolism; PVR, peripheral vascular resistance; RV, right ventricular; and V/Q, ventilation‐perfusion.
Figure 2
Figure 2. The role of MCS in the management of massive or submassive PE.
ECMO indicates extracorporeal membrane oxygenation; MCS, mechanical circulatory support; PERT, pulmonary embolism response team; VA‐ECMO, venoarterial extracorporeal membrane oxygenation; VAV‐ECMO, venoarterial‐venous extracorporeal membrane oxygenation; and VV‐ECMO, venovenous extracorporeal membrane oxygenation.
See this image and copyright information in PMC

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