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

Veno-arterial ECMO for the Supportive Treatment of High-risk Pulmonary Embolism Patients

Some patients with acute high-risk PE remain clinically unstable despite the initial supportive therapy and may require additional measures either before, during, or after reperfusion treatments and in cases with no reperfusion strategies. Until recently, case reports and small case series have supported the role of veno-arterial ECMO to improve the cardiopulmonary conditions of these unstable subjects.[11]

Meneveau et al.[5] report a series of 180 high-risk PE patients in a multicentre, retrospective and observational study. A total of 128 patients were treated without ECMO and their 30-day mortality was 43% as compared with 61.5% in those treated with ECMO (P = 0.008), who had, as expected, a more severe presentation. Among patients with ECMO, the 30-day mortality was 77.7% in those without a reperfusion strategy, 76.5% in those with associated thrombolysis, and 29.4% when ECMO was performed after surgical embolectomy (P = 0.008). Of note, among patients with ECMO, 38.5% had an in-hospital major bleeding event, without a significant difference across groups. The authors conclude that ECMO in patients with failed fibrinolysis and in those with no reperfusion strategies seems to be associated with a particularly unfavourable prognosis. ECMO does not appear justified as a stand-alone treatment strategy in PE patients, but shows promise as a complement to surgical embolectomy.

The interpretation of the results of this important study requires the analysis of the relevant limitations, which the authors have correctly discussed. The retrospective nature of the study has not allowed uniform decision-making about the treatment strategies adopted, including ECMO.

Therefore, the treated groups are not homogeneous, and any statistics should be regarded with caution. Nevertheless, the reduced mortality observed in patients with high-risk PE and treated with surgical embolectomy (with supportive post-operative ECMO) represents a relevant finding in favour of the surgical approach. In this case, the exact role of ECMO in achieving these favourable results is not clear without a comparative non-ECMO surgical group.

The most relevant finding of this study is the apparent lack of efficacy of veno-arterial ECMO in the majority of high-risk PE patients and a potential for a detrimental effect due to major bleeding events observed in 38.5% of ECMO cases. This information will probably be captured in the updated version of the ESC PE guidelines, which will be available in the summer of 2019.

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