Efficacy and safety of extracorporeal membrane oxygenation for high-risk pulmonary embolism: A systematic review and meta-analysis

Abstract

High-risk pulmonary embolism (PE) requires hemodynamic and respiratory support along with reperfusion strategies. Recently updated European guidelines assign a low class of recommendation to extracorporeal membrane oxygenation (ECMO) for high-risk PE. This systematic review assessed clinical outcomes after ECMO in high-risk PE. We searched electronic databases including PubMed, Embase and Web of Science from January 2000 to April 2020. Efficacy outcomes included in-hospital survival with good neurological outcome and survival at follow-up. Safety outcomes included lower limb ischemia and hemorrhagic and ischemic stroke. Where possible (absence of high heterogeneity), meta-analyses of outcomes were undertaken using a random-effects model. We included 16 uncontrolled case-series (533 participants). In-hospital survival with good neurological outcome ranged between 50% and 95% while overall survival at follow-up ranged from 35% to 95%, both with a major degree of heterogeneity (I2 > 70%). The prevalence of lower limb ischemia was 8% (95% CI 3% to 15%). The prevalence of stroke (either hemorrhagic or ischemic) was 11% (95% CI 3% to 23%), with notable heterogeneity (I² = 63.35%). Based on currently available literature, it is not possible to draw definite conclusions on the usefulness of ECMO for high-risk PE. Prospective, multicenter, large-scale studies or nationwide registries are needed to best define the role of ECMO for high-risk PE. PROSPERO registration ID: CRD42019136282.

Effectiveness of pharmacological thrombolysis on clinical outcomes in high-risk pulmonary embolism patients with extracorporeal membrane oxygenation: a nationwide inpatient database study

“…Second, the present study was unable to identify whether patients received ECMO after failing pharmacological thrombolysis or whether they initially received ECMO and then pharmacological thrombolysis on the day of admission. Third, the incidence of major bleeding events in the present study was considerably lower than in the previous German study (intracranial bleeding, 1.2% vs. 4.9%) [5] and other previous studies [7,20]. Given that the sensitivity of the diagnosis might have been low in our database [21],…”

Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism

“…4 In this specific patient cohort, temporary use of mechanical circulatory support via extracorporeal membrane oxygenation (ECMO) as a bridging therapy during pharmacological or mechanical thrombolysis or embolectomy might improve outcomes. 6,7 Given hemodynamic collapse, these patients typically require venoarterial (VA) support as opposed to venovenous (VV) ECMO support. To date, there is a paucity of data reporting usage and outcomes of ECMO alone or in combination with mechanical or pharmacological thrombolysis or embolectomy in the setting of high-risk PE.…”

Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient

“…ECMO seemed to provide a bridge to additional life-saving measures, especially in patients with severe cor pulmonale, [7,8] and served as a bridge during pharmacological or mechanical thrombolysis or embolectomy. [9][10][11] Due to the variety of treatments available alone or in combination, the optimal strategies are still controversial and are being explored. A recent systematic review including 50 case series or case reports comprising 128 patients who required ECMO found that initiation of ECMO before systemic and catheterdirected thrombolytics was a safe and effective therapy and offered acceptable outcomes.…”