VA-ECMO First Therapy Is An Effective Management Strategy For Massive Pulmonary Embolism Patients.
Jaideep Das Gupta, M.D., Sundeep Guliani, M.D., John Marek, M.D., Muhammad A. Rana, M.D., Erik Kraai, M.D., Jon Marinaro, M.D..
University of New Mexico, Albuquerque, NM, USA.
OBJECTIVES: Treatment of massive pulmonary embolism is controversial, with mortality rates ranging from 25% to 65%. Patients commonly present with profound shock and/or cardiac arrest. Veno-arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is increasingly being utilized as a form of acute cardiopulmonary support in critically ill patients. We reviewed our institutional experience utilizing VA-ECMO for patients presenting with advanced shock and/or cardiac arrest from massive pulmonary embolism.
METHODS: From March 2017 to July 2019 we retrospectively reviewed all patients (n=17) at our institution with massive pulmonary embolism (PE) who were placed on VA-ECMO for initial hemodynamic stabilization.
RESULTS: Mean patient age and body mass index was 55.8 years and 31.8, respectively. Ten of 17 patients (59%) underwent cardiopulmonary resuscitation (CPR) prior-to or during VA-ECMO cannulation. All patients had evidence of profound shock with mean initial lactate of 8.95 and mean pH of 7.14. (Table 1) Seventeen of 17 (100%) cannulations were performed percutaneously, with 42% (n=7) of patients placed on VA-ECMO while awake and utilizing local analgesia. Five of 17 patients (29%) required reperfusion cannulas, with 0% incidence of limb loss. Overall survival was 13 in 17 patients (76%), with causes of death resulting from anoxic brain injury (n=2), bacteremia (n=1), and CPR-induced hemorrhage from liver laceration (n=1). Twelve of 13 patients (92.3%) survived to hospital discharge without evidence of neurologic insult. Mean duration of VA-ECMO run for survivors was 102.9 hours. Mean duration from ECMO cannulation to lactate clearance (<2.0) in survivors was 11.1 hours. Definitive PE therapy for the 13 survivors was anticoagulation alone during ECMO support in ten of 13 (77%) patients and three (23%) required percutaneous thrombectomy and catheter-directed thrombolysis for persistent RV dysfunction. Mean ICU and hospital length of stay for survivors was 13.8 and 18.4 days, respectively.
CONCLUSIONS: VA-ECMO was effective at salvaging highly unstable patients with massive pulmonary embolism. Survivors had rapid reversal of multiple organ failure with ECMO as their primary therapy. Majority of survivors required ECMO and anticoagulation alone for definitive therapy of their massive PE.
|Awake VA-ECMO||7 (42%)|
|ECMO duration (hrs)*||102.9 (45-218)|
|ICU LOS (days)*||13.8 (4-44)|
|Hospital LOS (days)*||18.4 (5-52)|
|Placement of Reperfusion cannula||5 (29%)|
|Treated with anticoagulation alone*||10 (77%)|
|Treated additional with additional invasive interventions||3 (23%)|
|*In survival patients (n=13)|
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