Extracorporeal Cardiopulmonary Support in Acute High-risk Pulmonary Embolism

Still Waiting for Solid Evidence

Nazzareno Galiè; Massimiliano Palazzini; Alessandra Manes

Disclosures

Eur Heart J. 2018;39(47):4205-4207. 

In This Article

Acute Pulmonary Embolism

Arterial and venous thrombo-embolic conditions are estimated to account for one in four deaths worldwide and are the leading cause of overall mortality.[1] Venous thrombo-embolism (VTE) includes deep-vein thrombosis and acute pulmonary embolism (PE) whose combined incidence rate is variable from 115 to 269 cases and with mortality rates from 9.4 to 32.3 cases per 100 000 people.[1] Despite the fact that both the incidence and mortality rates for VTE are decreasing in developed countries, the management of specific patient subsets such as those with high-risk PE is still challenging.[2,3] According to the 2014 European Society of Cardiology (ESC) PE guidelines,[3] high-risk PE is defined by cardiac arrest, or persistent hypotension (i.e. systolic blood pressure < 90 mmHg or a systolic pressure drop by 40 mmHg, for >15 min, if not caused by new-onset arrhythmia, hypovolaemia, or sepsis) accompanied by signs of end-organ hypoperfusion. High-risk PE is a medical emergency; it accounts for ~5% of all acute PE cases, and hospital mortality ranges from 15% to 50% according to specific patient features and treatment strategies.[4] In addition, non-hypotensive patients with acute PE and designated at intermediate risk according to clinical variables, myocardial injury biomarkers, and right ventricular dysfunction deserve intensive monitoring due to possible progression to advanced right heart failure and high-risk status despite initial treatment strategies.[2–4]

The initial management of high-risk PE patients, in addition to anticoagulation, includes haemodynamic and respiratory support by cautious volume expansion, diuretic treatment, pharmacological inotropic therapy, and oxygen administration.[3]Interestingly, the 2014 ESC PE guidelines also report that 'experimental evidence suggests that extracorporeal cardiopulmonary support can be an effective procedure in massive PE' based on case reports and patients series.[3] The supportive therapy will bridge the patient to the cornerstone of the management of high-risk PE patients, which is reperfusion therapy. Reperfusion includes full-dose systemic thrombolysis, surgical pulmonary embolectomy (in the case of contraindication or failure of thrombolysis), and percutaneous catheter-directed treatments (in the case of unavailability of surgical embolectomy).

The study of Meneveau et al.[5] published in the current issue of the European Heart Journal provides useful information on the potential role of extracorporeal membrane oxygenation (ECMO) for the supportive treatment of high-risk PE patients.

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