Journal Article

Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

Leprince, Pascal, Combes, Alain, Lebreton, Guillaume, Corsi, Fillipo, Nieszkowska, Ania, Trouillet, Jean-Louis, Bréchot, Nicolas, Schmidt, Matthieu, Luyt, Charles-Edouard, Chastre, Jean, Hekimian, Guillaume

2017

Overview

Background Despite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation. Methods ECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted. Results Seventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge. Conclusions VA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.

• Publisher: BioMed Central,Springer Nature B.V,BMC
• Subject: Adolescent / Adult / Aged / Anticoagulants / Cardiogenic shock / Cardiopulmonary resuscitation / Catheters / CPR / Critical care / Critical Care Medicine / Embolisms / Emergency Medicine / Extracorporeal membrane oxygenation / Extracorporeal Membrane Oxygenation - methods / Extracorporeal Membrane Oxygenation - mortality / Extracorporeal Membrane Oxygenation - statistics & numerical data / Female / Health risk assessment / Humans / Intensive / Intensive Care Units - organization & administration / Intensive Care Units - statistics & numerical data / Life Sciences / Long-term quality of life / Male / Massive pulmonary embolism / Medicine / Medicine & Public Health / Middle Aged / Mortality / Paris / Pulmonary arteries / Pulmonary Embolism - mortality / Pulmonary Embolism - therapy / Pulmonary embolisms / Retrospective Studies / Severity of Illness Index / Statistics, Nonparametric / Survival Analysis / Survivors - statistics & numerical data / Tertiary Care Centers - organization & administration / Tertiary Care Centers - statistics & numerical data