Abstract Body (Do not enter title and authors here): Introduction: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly employed for cardiopulmonary support in cases of pulmonary embolism associated with hemodynamic collapse or cardiac arrest. However, the optimal reperfusion strategy in these situations remains unclear.
Aim: We evaluated the association between reperfusion strategy and in-hospital mortality in patients with high-risk PE supported with VA-ECMO.
Methods: We conducted a single-center retrospective study of adult patients cannulated for VA-ECMO support due to acute high-risk PE between 2015-2024. Demographic, imaging, procedural, and outcome data were collected. Univariate and multivariate logistic regression analyses were performed to identify whether reperfusion therapies were associated with outcomes. Our primary outcome was mortality.
Results: We included 58 patients (mean age 51.7 ± 14.3 years, 55% female) supported on VA-ECMO for high-risk PE. Of these, 40 (69%) were cannulated following cardiac arrest and 18 (31%) for shock. The majority of the cohort (46, 79.3%) received reperfusion therapy in addition to ECMO support, whereas 12 patients (20.1%) were supported on ECMO alone. An ECMO alone approach was exclusively used in patients presenting with cardiac arrest (12, p=0.009). In patients supported on ECMO alone, only 1 patient (8.3%) survived to discharge compared to 22 patients receiving reperfusion therapy (47.8, p=0.013). On univariate analysis, ECMO alone (OR 10.1, 95% CI 1.20-84.6) and cannulation following cardiac arrest (OR 5.26, 95% CI 1.59-17.5) were associated with increased odds of mortality. In multivariate analysis after adjusting for age, sex, PESI, and cardiac arrest, patients treated with ECMO alone had significantly higher rates of in-hospital mortality (OR 12.85, 95% CI 1.26-130.88).
Conclusions: In this cohort of high-risk PE patients supported with VA-ECMO patients who were not treated with adjunctive reperfusion therapies had 12 times higher mortality rates, emphasizing the therapeutic value of combining VA ECMO with reperfusion strategies. Larger studies are needed to guide reperfusion strategies and improve outcomes in this critically ill population.