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Crit Care. 2017 Mar 28;21(1):76. doi: 10.1186/s13054-017-1655-8.

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

Author information

1
Dipartimento di Anestesia e Rianimazione, Policlinico Universitario A. Gemelli, Università Cattolica Del Sacro Cuore, Rome, Italy.
2
Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
3
Cardiac Surgery Department, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
4
Medical Intensive Care Unit, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre-et-Marie-Curie, Paris 6, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France. matthieu.schmidt@aphp.fr.
5
Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France. matthieu.schmidt@aphp.fr.

Abstract

BACKGROUND:

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.

METHODS:

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.

RESULTS:

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.

CONCLUSIONS:

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.

KEYWORDS:

Cardiogenic shock; Extracorporeal membrane oxygenation; Long-term quality of life; Massive pulmonary embolism

PMID:
28347320
PMCID:
PMC5369216
DOI:
10.1186/s13054-017-1655-8
[Indexed for MEDLINE]
Free PMC Article

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