Optimal reperfusion strategy in acute high-risk pulmonary embolism requiring extracorporeal membrane oxygenation support: a systematic review and meta-analysis.

Romain Chopard, Peter Nielsen, Fabio Ius, Serghei Cebotari, Fiona Ecarnot, Hugo Pilichowski, Matthieu Schmidt, Benedict Kjaergaard, Iago Sousa-Casasnovas, Mehrdad Ghoreishi, Rajeev L Narayan, Su Nam Lee, Gregory Piazza, Nicolas Meneveau

Journal: The European respiratory journal 2022;60(5):2102977

PMID: 35487534

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Abstract

BACKGROUND

The optimal pulmonary revascularisation strategy in high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial.

METHODS

We conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic thrombolysis, catheter-directed thrombolysis or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes.

RESULTS

We identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion (of whom 85.9% had surgical embolectomy), while 67.6% received other strategies. The mortality rate was 22.6% in the mechanical reperfusion group and 42.8% in the "other strategies" group. The pooled odds ratio for mortality with mechanical reperfusion was 0.439 (95% CI 0.237-0.816) (p=0.009; I=35.2%) other reperfusion strategies and 0.368 (95% CI 0.185-0.733) (p=0.004; I=32.9%) for surgical embolectomy thrombolysis. The rate of bleeding in patients under ECMO was 22.2% in the mechanical reperfusion group and 19.1% in the "other strategies" group (OR 1.27, 95% CI 0.54-2.96; I=7.7%). The meta-regression model did not identify any relationship between the covariates "more than one pulmonary reperfusion therapy", "ECMO implantation before pulmonary reperfusion therapy", "clinical presentation of PE" or "cancer-associated PE" and the associated outcomes.

CONCLUSIONS

The results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favourable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.

Address: Dept of Cardiology, University Hospital Jean Minjoz, Besançon, France.; EA3920, University of Burgundy Franche-Comté, Besançon, France.; F-CRIN, INNOVTE Network, Saint Etienne, France.; Dept of Cardiology, Aalborg University Hospital, Aalborg, Denmark.; Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark.; These two authors contributed equally.; Dept of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany.; INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France.; Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France.; Dept of Cardiothoracic Surgery, Aalborg University Hospital, Hobrovej, Denmark.; Dept of Cardiology, General University Hospital Gregorio Maranon, Complutense University, Madrid, Spain.; Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.; Nuvance Health - Vassar Brothers Medical Center, Poughkeepsie, NY, USA.; Division of Cardiology, Hackensack University Medical Center, Rutgers New Jersey Medical School, Newark, NJ, USA.; Dept of Internal Medicine, St Vincent's Hospital, The Catholic University of Korea, Suwon, Korea.; Division of Cardiovascular Medicine, Dept of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.; Dept of Cardiology, University Hospital Jean Minjoz, Besançon, France [email protected].

DOI: 10.1183/13993003.02977-2021

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MeSH Terms: Humans, Extracorporeal Membrane Oxygenation, Embolectomy, Pulmonary Embolism, Acute Disease, Reperfusion, Thrombolytic Therapy, Treatment Outcome