Perioperative Extracorporeal Membrane Oxygenation-Based Protocol for Massive Acute Pulmonary Embolism

Purpose At our institution, since 2012, we have applied a protocol using perioperative veno-arterial extracorporeal membrane oxygenation (v-a ECMO) support in all patients with acute massive pulmonary embolism, in order to reduce the impact of hemodynamic instability. In this study, we present the results of perioperative ECMO-therapy in these high-risk surgical patients. Methods We retrospectively reviewed all patients who underwent embolectomy due to massive acute pulmonary embolism at our institution between 11/2012 and 10/2018. In these patients, v-a ECMO was implanted percutaneously in the femoral vessels before the beginning of the anaesthesia, if it had not already been implanted before. At the end of operation, cardiopulmonary bypass support was switched again to v-a ECMO support, which was continued perioperatively at the intensive care unit. Results During the study period, 20 patients (median age 64 years, 75% male patients, 10% cardiac redos) underwent pulmonary embolectomy for acute massive embolism. Among these patients, preoperatively, 7 (35%) patients showed concomitant chronic thromboembolic pulmonary artery hypertension (CTEPH), 11 (55%) patients required mechanical ventilation, 14 (70%) patients required v-a ECMO support for cardiogenic shock and 11 (55%) patients had undergone thrombolysis. Median time under preoperative ECMO support amounted to 2 days. V-a ECMO was implanted before beginning of the anaesthesia in the remaining 6 (30%) patients. Intraoperatively, cardiopulmonary and cross clamp times amounted to a median of 127 and 53 minutes, respectively. Seven (35%) patients underwent pulmonary endarterectomy for concomitant CTEPH. V-a ECMO was continued after the end of the operation in all patients and weaned successfully after a median of 5 days. Twelve (60%) patients were extubated before ECMO weaning. Six (30%) patients required prolonged ventilation and underwent tracheostomy. Three (15%) patients required rethoracotomy for bleeding and 5 (25%) patients required new dialysis treatment. One (5%) patient showed lung reperfusion injury. Two (10%) patients died in-hospital of sepsis. Conclusion Ourv-a ECMO based protocol for massive acute pulmonary embolectomy led to stabilization of preoperative compromised haemodynamic. Postoperative ECMO provided good postoperative results in high risk patients.