Extracorporeal membrane oxygenation and surgical embolectomy for high-risk pulmonary embolism

Abstract

Patients with high-risk pulmonary embolism (PE) presenting with cardiogenic shock refractory to supportive measures have a high mortality [1, 2]. Therapeutic success depends on rapid haemodynamic stabilisation and restoration of pulmonary blood flow. Thrombolytic therapy is the most widely used recanalisation strategy, but this treatment has substantial drawbacks including a high rate of bleeding complications and limited efficacy in patients with large embolic burden or in patients with recurrent PE presenting with acute-on-chronic events [3-8]. Surgical treatment of massive PE was introduced 110 years ago by Dr. Trendelenburg, but was widely abandoned due to high mortality rates [4, 9]. The unsatisfactory surgical results were often related to the compromised clinical status of the patients, especially those who had already undergone thrombolysis and entered the operation room with advanced cardiogenic shock in need of cardiopulmonary resuscitation (CPR) [1, 2, 9-11]. Thus, the cornerstone for improving the results of surgical embolectomy may lie in the stabilisation of the preoperative haemodynamic condition, which can be achieved by veno-arterial extracorporeal membrane oxygenation (v-a ECMO) [2, 12, 13]. At our institution, in November 2012, we introduced a pulmonary embolism response team (PERT) consisting of pneumologists, cardiologists, radiologists and cardiothoracic surgeons, and a standard operating procedure for patients with high-risk PE. Per protocol, thrombolytic therapy was not to be instituted prior to a PERT decision. v-a ECMO support was the preferred rescue therapy for patients who remained in cardiogenic shock or under CPR despite supportive measures.

Efficacy and Safety of Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of High-Risk Pulmonary Embolism: A Retrospective Cohort Study

“…ECMO is a rapid and reliable mechanical circulatory support device that decreases RV volume overload (5), and is also recommended as a treatment option for PE patients with refractory circulatory collapse or cardiac arrest. The overall survival rate of patients who receive ECMO for high PE has been reported to be 38-67% (5)(6)(7)(8)19). For patients who required CPR prior to ECMO initiation, the survival rate was only 13-27%, similar to our result (20%).…”

“…Veno-arterial extracorporeal membrane oxygenation (ECMO), a temporary mechanical circulatory support device, has been increasingly used over the past 20 years to treat high-risk PE. Several case series studies (5)(6)(7)(8) have demonstrated the potential benefit of ECMO in high-risk PE patients with several indications, including haemodynamic support for profound shock or cardiac arrest, contraindication to systemic thrombolysis, failed reperfusion therapy, and cardiogenic shock after surgical embolectomy.…”

Outcome after surgical embolectomy for acute pulmonary embolism

“…Our data also demonstrate that peri-operative management has changed throughout the years. In particular, peri-operative veno-arterial (VA) ECMO support has been integrated into the management of PE patients as well as current guideline recommendations 6,14–16 . In our study, ECMO was used in 15 patients; the 30-day survival rate was 60%, which is comparable to the observations of other researchers 16–18 .…”

Use of extracorporeal membrane oxygenation in high‐risk acute pulmonary embolism: A systematic review and meta‐analysis

“…Among the 421 studies identified by the search strategy, 106 studies were deemed eligible and 21 studies were eventually included in the analysis, for a total population of 635 patients with acute high‐risk PE receiving ECMO support 11‐31 . Exclusion reasons were: overlapping populations ( n = 10), studies not focused on ECMO use in PE ( n = 4), commentary papers ( n = 3), studies not reporting outcome of interest ( n = 1), and case reports/cases series including < 4 patients ( n = 67).…”