BACKGROUNDCurrent guidelines for massive pulmonary embolism (PE) treatment recommend primary reperfusion therapy and the option of extracorporeal membrane oxygenation (ECMO). However, these recommendations might not be optimal for patients with poor prognoses who are in cardiogenic shock (CS) or require cardiopulmonary resuscitation (CPR).OBJECTIVEEvaluate the impact of ECMO support on the clinical outcome of patients with massive PE complicated by CPR or CS.DESIGNRetrospective review of medical records.SETTINGA university hospital, South Korea.PATIENTS AND METHODSWe collected data on patients from 2004 through 2009 (stage 1) and from 2010 through June 2017 (stage 2). Patients with confirmed massive PE received medical therapy (stage 1) or medical therapy that included extracorporeal membrane oxygenation (ECMO) support (stage 2).MAIN OUTCOME MEASURESAll-cause mortality at 90 days after therapy.SAMPLE SIZE9 patients with confirmed massive PE that received medical therapy (stage 1); 14 patients with confirmed massive PE that received medical therapy with ECMO support (stage 2).RESULTSIn stage 1, 5 of 9 patients received systemic thrombolysis and 4 patients received anticoagulation. Thirteen of the 14 stage 2 patients received anticoagulation with ECMO support and one patient received systemic thrombolysis with ECMO support. Tricuspid annular plane systolic excursion in stage 1 was lower than in stage 2. Proximal PE in chest CT was more common in stage 2. Survival was significantly improved at 90 days for patients in stage 2 (log-rank, P=.048). There were no differences in baseline characteristics, ECMO complications and transfusion between survivors and nonsurvivors in stage 2.CONCLUSIONSAnticoagulation with ECMO support is associated with good survival rate outcomes compared with medical therapy alone.LIMITATIONSRelatively small number of patients and retrospective design.

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.

PurposeExtracorporeal membrane oxygenation (ECMO) is used to treat patients in critical condition with cardiogenic shock. However, few studies have examined the effect of old age in ECMO survival. This study analyzed the impact of age on ECMO survival of patients with cardiac failure, and analyzed predictive factors for survival according to age.Materials and methodsWe retrospectively reviewed the medical records of 95 patients who required veno-arterial (V-A) ECMO between May 2009 and May 2016 at a single center. Patients were classified into “age ≥65” (n=48, 50.5%) and “age <65” (n=47, 49.5%) groups.ResultsThe age ≥65 group was significantly associated with increased mortality (HR: 1.715; 95% CI =1.038–2.831) at 90 days after ECMO initiation. These associations were attenuated and did not retain statistical significance after adjustment for comorbidities (HR: 1.485; 95% CI =0.844–2.614). To determine predictive factors of mortality, multivariate logistic analysis revealed that age ≥65 (OR 5.750; 95% CI [1.508–21.920]; P=0.010), low pre-ECMO serum bicarbonate (OR 0.884; 95% CI [0.788–0.991]; P=0.035), and high pre-ECMO serum creatinine (OR 4.546; 95% CI [1.021–20.239]; P=0.047) were significantly associated with survival to 90 days. By analyzing two groups separately, high pre-ECMO serum potassium level (OR 3.552; 95% CI [1.023–12.331]; P=0.046) was the only independent predictor in patients aged <65 years while low Glasgow Coma Scale score (OR 0.698; 95% CI [0.478–1.019]; P=0.063) showed a considerable trend toward significance in patients aged ≥65.ConclusionOlder age was not an independent risk factor for mortality at 90 days among V-A ECMO patients. In addition, our study provides understanding of the differences in predictive factors for ECMO survival according to age. Pre-ECMO laboratory findings and mental status can assist clinicians in the prediction of a patient’s prognosis.

No abstract

Background: Many studies have reported both systemic inflammatory response and malnutrition provide valuable predictions of prognosis in patients with acute coronary syndrome (ACS). This study aims to assess the association between the Glasgow prognostic score (GPS) by combining C-reactive protein and serum albumin concentration, and clinical outcomes in patients with ACS. Methods: This retrospective study included patients admitted for ACS between June 2010 and May 2013 in St. Vincent's Hospital, The Catholic University of Korea. In this study, high GPS was defined as a GPS ! 1. Primary outcomes were 12-month all-cause and cardiovascular mortality, stroke, stent thrombosis and target vessel revascularization. We used an inverse probability of treatment weighting (IPTW) analysis to adjust for potential confounding covariates and presented event rates with Kaplan-Meier curves. Results: Total 593 patients were included and follow-up for a median 3.7 years. The patients were classified into two groups: GPS = 0 (n = 424, 71.5%) and GPS ! 1 (n = 169, 28.5%). The incidences of primary outcomes were 4% and 8.9% for the GPS = 0 and GPS ! 1, respectively. The primary outcomes and all-cause mortality difference between the two groups were significantly within 1 month in the Kaplan-Meier curve analysis (log rank p < 0.001, log rank p < 0.001, respectively). IPTW analysis showed high GPS was independently associated with higher incidence of primary outcomes (HR: 2.206; 95% CI: 1.085-4.486; p = 0.029), higher all-cause mortality (HR: 5.963; 95% CI: 2.068-17.190; p < 0.001) and higher cardiovascular mortality (HR: 6.122; 95% CI: 1.882-19.914; p = 0.003). Conclusions: High GPS is independently associated with both total and cardiovascular mortality in patients with ACS. Hence, GPS could be helpful in predicting mortality in ACS patients.