Results of systemic fibrinolysis vs. ECMO VA in patients with profound shock (SCAI D-E) due to acute pulmonary embolism

Abstract Introduction Fibrinolysis is the recommended rescue treatment for patients with hemodynamic instability due to pulmonary embolism (PE). However, as shock progresses (SCAI-D-E), it may be insufficient due to poor perfusion caused by the obstructive shock of the PTE. New catheter-based therapies could play a role in these patients; however, they have the significant disadvantage of requiring a delay (from transporting the patient to the catheterization laboratory to the procedure itself), during which time the shock worsens and becomes irreversible. Our objective is to describe the treatment outcomes of patients with SCAI-D-E who were treated with ECMO-VA and anticoagulation versus rescue systemic fibrinolysis. Methods This is a retrospective study of our series of patients with PE admitted to the Coronary Care Unit of a tertiary center. We analyzed the subgroup of high-risk patients with profound cardiogenic shock (SCAI-D-E) with respect to the treatment they received. Results At our center, all patients diagnosed with Intermediate-High and High-risk PE are admitted to the Coronary Care Unit. Our current series includes 116 patients. We separated those who met the High-risk criteria but also had to be in uncontrolled profound shock or in cardiorespiratory arrest (SCAI D or E). The final total was 25 patients with a mean age of 56.5 years, and 56% were women. All patients received anticoagulation therapy, but were also divided into two groups: A) those who received systemic fibrinolysis (18 patients) and B) those who underwent ECMO-VA (7 patients) without systemic fibrinolysis or Targeted Catheter Therapy. Mortality in the fibrinolysis group was 33% (6 cases) vs. 14.3% (1 case) in the ECMO-VA group. Similarly, hemorrhagic complications classified as major bleeding were higher in the fibrinolysis group 44% (8 patients) vs 28% (2 cases) in the ECMO-VA group. Conclusions We await more powerful studies. In patients with profound cardiogenic shock (SCAI D-E) due to PE, anticoagulation and ECMO-VA alone are a great alternative to traditional rescue treatment with systemic fibrinolysis.