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

• Published in: Critical care (London, England) England), 2017-03, Vol.21 (1), p.76-76, Article 76
• Main Authors: Corsi, Fillipo, Lebreton, Guillaume, Bréchot, Nicolas, Hekimian, Guillaume, Nieszkowska, Ania, Trouillet, Jean-Louis, Luyt, Charles-Edouard, Leprince, Pascal, Chastre, Jean, Combes, Alain, Schmidt, Matthieu
• Format: Article
• Language: English
• Subjects: Adolescent; Adult; Aged; Anticoagulants; Cardiogenic shock; Cardiopulmonary resuscitation; Catheters; CPR; Critical care; Embolisms; Extracorporeal membrane oxygenation; Extracorporeal Membrane Oxygenation - methods; Extracorporeal Membrane Oxygenation - mortality; Extracorporeal Membrane Oxygenation - statistics & numerical data; Female; Health risk assessment; Humans; Intensive Care Units - organization & administration; Intensive Care Units - statistics & numerical data; Life Sciences; Long-term quality of life; Male; Massive pulmonary embolism; 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
• ISSN: 1364-8535; 1466-609X; 1364-8535; 1366-609X
• DOI: 10.1186/s13054-017-1655-8

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. 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. 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. 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.