Scientists and clinicians at the German Center for Lung Research (DZL) were able to show that the perioperative use (before, during and after an operation) of the veno-arterial, extracorporeal membrane oxygenation (ECMO) improves the prognosis of patients with an acute pulmonary embolism.
The acute bilateral pulmonary embolism is a rare disease, in which a cardiogenic shock occurs with consecutive impairment of further organs such as the liver or kidneys. The surgical therapy of choice is currently the so-called Trendelenburg operation. With hemodynamic and respiratorily unstable patients, some of whom underwent lysis therapy preoperatively, the mortality rate of this operation lies, however, at over 20%. An initial treatment option is thus the single systemic lysis of the gold standard. The desired immediate stabilization of the hemodynamics does, however, not always occur and many patients require reanimation. To improve the prognosis of patients with a pulmonary embolism, the interdisciplinary PER Team (Pulmonary Embolism Response Team) was established in 2012 in Hanover. This team of heart surgeons, pneumologists, cardiologists and radiologists evaluates and makes individual decisions for each patient on the the therapeutic possibilities of the acute pulmonary embolism. In 2012, the scientists and clinicians at BREATH, the Hannover site of the German Center for Lung Research, created for the first time for a pulmonary embolism patient a treatment protocol with emphasis on the veno-arterial extracorporeal membrane oxygenation (ECMO) for acute hemodynamic stabilization. The protocol ensures that patients with an acute pulmonary embolism are stabilized by using the veno-arterial ECMO, in order to minimize the consequences of hemodynamic shock. After 1-3 days, the surgical embolectomy is carried out still under the protection of the veno-arterial ECMO. After the successful removal of the thrombotic material, support from the ECMO is continued for a further 2-3 days in order to allow the patient to be slowly weaned off the ECMO. Whilst the circulation gets used to the new situation, depending on the hemodynamic and respiratory situation of the patient, extubation can already be carried out before the ECMO is ended. This protocol forms the basis for the study: „Extracorporeal membrane oxygenation and surgical embolectomy for high-risk pulmonary embolism“, published in 2019 in the European Respiratory Journal. In this study, between 2012 and 2018, 36 patients with massive, life-threatening pulmonary embolism were included and initially supplied with a veno-arterial ECMO. Nineteen (53%) of these patients received an unsuccessful systemic lysis treatment. In twenty (55%) of these patients, a pulmonary embolectomy was carried out. Each of these patients was supplied, according to protocol, with veno-arterial ECMO support in the intensive care unit and monitored. Of these patients, one died (5%) due to a septic event. All other patients were on average discharged from hospital after 22 days with no neurological anomalies. Comparison of this new protocol with the previous therapy option shows a massively improved prognosis and gives rise to hope for patients with this rare disease.
More information on the results of the study can be found here in the original publication: Extracorporeal membrane oxygenation and surgical embolectomy for high-risk pulmonary embolism. Eur Respir J 2019; 53: 1801773.
Photo: MHH HTTG
Dr. Fabio Ius and PD Dr. Serghei Cebotari from the Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery (HTTG)