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Background and objectivesThe optimal pulmonary revascularization strategy in high-risk pulmonary embolism (PE) requiring implantation of extra corporeal membrane oxygenation (ECMO) remains controversial. We conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic, catheter-directed thrombolysis, or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes.Methods and resultsWe identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion, (of whom 85.9% had surgical embolectomy), while 67.61% received other strategies. The mortality rate was 26.4% in the mechanical reperfusion group, and 42.8% in the other strategy group. The pooled OR for mortality with mechanical reperfusion was 0.43 (95%CI, 0.23–0.997); p=0.009; I2=35.2%) versus other reperfusion strategies; and 0.36 (95% CI, 0.18–0.73; p=0.009; I2 =32.9%) for surgical embolectomy versus thrombolysis. The rate of bleeding in patients under ECMO was 24.5% in the mechanical reperfusion group and 19.6% in the other reperfusion group (OR, 1.26; 95% CI, 0.54–2.92; I2, 7.7%). The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy”, “ECMO implantation before pulmonary reperfusion therapy”, clinical presentation of PE, or cancer-associated PE, and the associated outcomes.ConclusionsThe results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favorable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.

Valganciclovir (VGCV) and ganciclovir (GCV) doses must be adjusted according to indication, renal function and weight. No specific therapeutic exposure values have been established. We aimed to evaluate the adequacy of VGCV/GCV doses, to assess the interpatient variability in GCV serum levels, to identify predictive factors for this variability and to assess the clinical impact. This is a prospective study at a tertiary institution including hospitalized patients receiving VGCV/GCV prophylaxis or treatment. Adequacy of the antiviral dose was defined according to cytomegalovirus guidelines. Serum levels were determined using High-Performance Liquid Chromatography. Blood samples were drawn at least 3 days after antiviral initiation. Outcome was considered favorable if there was no evidence of cytomegalovirus infection during prophylaxis or when a clinical and microbiological resolution was attained within 21 days of treatment and no need for drug discontinuation due to toxicity. Seventy consecutive patients [74.3% male/median age: 59.2 years] were included. VGCV was used in 25 patients (35.7%) and GCV in 45 (64.3%). VGCV/GCV initial dosage was deemed adequate in 47/70 cases (67.1%), lower than recommended in 7/70 (10%) and higher in 16/70 (22.9%). Large inter-individual variability of serum levels was observed, with median trough levels of 2.3 mg/L and median peak levels of 7.8 mg/L. Inadequate dosing of VGCV/GCV and peak levels lower than 8.37 or greater than 11.86 mg/L were related to poor outcome. Further studies must be performed to confirm these results and to conclusively establish if VGCV/GCV therapeutic drug monitoring could be useful to improve outcomes in specific clinical situations.

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