Extracorporeal Membrane Oxygenation in Massive Pulmonary Embolism

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Abstract

Extracorporeal Membrane Oxygenation (ECMO) has been suggested for cardiopulmonary support in patients with massive pulmonary embolism (PE) refractory to other treatment or as bridging to embolectomy. The survival benefit from ECMO in patients with massive PE remains unclear.

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Outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation for refractory cardiogenic shock.

Alain Combes, Pascal Leprince, Charles-Edouard Luyt … (2008)

To assess the outcomes and long-term quality-of-life of patients supported by extracorporeal membrane oxygenation (ECMO) for refractory cardiogenic shock. Refractory cardiogenic shock is almost always lethal without emergency circulatory support, e.g., ECMO. ECMO-associated morbidity and mortality plead for identification of early predictors of its failure, and detailed analyses of short- and long-term outcomes to refine patient selection and improve results. Outcomes of 81 patients given ECMO support for medical (n = 55), postcardiotomy (n = 16), or posttransplantation (n = 10) cardiogenic shock were evaluated. Thirty-four (42%) patients survived to hospital discharge; 57% suffered > or = 1 major ECMO-related complications. Independent predictors of intensive care unit death were: device insertion under cardiac massage (odds ratio [OR] = 20.68), 24 hr urine output < 500 mL (OR = 6.52), prothrombin activity < 50% (OR = 3.93), and female sex (OR = 3.89); myocarditides were associated with better outcomes (OR = .13). Sequelae and health-related quality-of-life were evaluated for 28 long-term survivors (median follow-up, 11 months), whose mean Short-Form 36 scores were significantly lower than matched healthy controls for physical role, general health, and social functioning, but higher than those reported for patients on chronic hemodialysis, with advanced heart failure, or after recovery from acute respiratory distress syndrome. ECMO support can rescue 40% of otherwise fatal cardiogenic shock patients but its initiation under cardiac massage or after renal or hepatic failure carried higher risks of intensive care unit death, while fulminant myocarditis had a better prognosis. Despite satisfactory mental health and vitality, long-term survivors' persistent physical and social problems might benefit from tailored medical or psychosocial interventions.

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Management Strategies and Determinants of Outcome in Acute Major Pulmonary Embolism: Results of a Multicenter Registry

Wolfgang Kasper, Stavros Konstantinides, Annette Geibel … (1997)

The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.