According to a study published in the Annals of Thoracic Surgery, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) appears to be an effective tool to optimize end-organ function as a bridge to recovery or intervention in patients with massive pulmonary embolism (PE).
Chetan Pasrija, MD, from the Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, and colleagues suggest this approach allows clinicians to better triage patients with massive PE to the appropriate therapy on the basis of right ventricular (RV) function recovery, residual thrombus burden, operative risk, and neurologic status.
This retrospective review of patient charts from January 2014 to August 2016 identified 20 consecutive patients who had RV-to-left ventricular ratios >1.0 and severe RV dysfunction before cannulation.
These patients were subsequently placed on VA-ECMO as an initial intervention for massive PE. Computed tomographic angiography had confirmed PE in all patients.
The median duration of ECMO support was 5.1 days, which resulted in significant improvement in end-organ function. Forty percent of patients received anticoagulation alone, 5% received catheter-directed therapy, and 55% had surgical pulmonary embolectomy. In one patient with a prolonged precannulation cardiac arrest, care was withdrawn after neurologic death was confirmed.
The in-hospital and 90-day survival rate was 95%. At discharge, 18 of 19 patients had normal RV function, whereas one patient who had received catheter-directed therapy had mild RV dysfunction.
Study limitations include the lack of a control group and lack of randomization resulting from the retrospective chart review design. Thus, no definitive conclusions can be drawn about the superiority of VA-ECMO.
Nonetheless, these findings do suggest that aggressive initiation of ECMO may result in better outcomes than salvage use of this therapy. Importantly, the authors note that this study was performed at a high-volume ECMO center, where there is a low complication rate, thus limiting the generalizability of these results to institutions where expertise in ECMO is lacking.
Pasrija C, Kronfli A, George P, et al. Utilization of veno-aterial extracorporeal membrane oxygenation for massive pulmonary embolism [published online November 23, 2017]. Ann Thorac Surg. doi:10.1016/j.athoracsur.2017.08.033