Pulmonary ECMO-ism: Let's add PEA to ECPR indications

Adding Extracorporeal Membrane Oxygenation to Cardiopulmonary Resuscitation in Out-of-Hospital Cardiac Arrest Due to Pulmonary Embolism: A Case Report

We present a challenging cardiopulmonary resuscitation scenario of an out-of-hospital cardiac arrest (OHCA) in a 21-year-old healthy woman recovering from a lower limb fracture who collapsed during a rehabilitation session at a community center. The combination of witnessed arrest, administration of immediate cardiopulmonary resuscitation, and effective communication to emergency services enabled a timely cannulation of extracorporeal membrane oxygenation in a cardiopulmonary resuscitation reference center. The cause of the cardiac arrest was pulmonary embolism, and the intensive care unit team opted for thrombolysis when she arrived after 40 minutes of cardiopulmonary resuscitation. The circulatory support given by venoarterial extracorporeal membrane oxygenation enabled adequate perfusion until the restoration of cardiac blood flow at 75 minutes after cardiac arrest. Despite the initial success, several life-threatening complications occurred. Anticoagulation is of paramount importance during extracorporeal support, as is thrombolysis in massive pulmonary embolism with cardiac arrest. However, this led to several complications. We highlight the importance of liaising with a wider team in such cases, including hepatobiliary surgery, vascular surgery, and interventional radiology, as doing so saved this patient's life without deficits.

Application of the TiPS65 score for out-of-hospital cardiac arrest patients with initial non-shockable rhythm treated with ECPR

Background

The TiPS65 score is a validated scoring system used to predict neurological outcomes in out-of-hospital cardiac arrest (OHCA) patients with shockable rhythm treated with extracorporeal cardiopulmonary resuscitation (ECPR). This study aimed to assess the predictive performance of the TiPS65 score in OHCA patients with initial non-shockable rhythm treated with ECPR.

Methods

This was a secondary analysis using the JAAM-OHCA registry, a multicenter prospective cohort study. The study included adult OHCA patients with initial non-shockable rhythm who underwent ECPR. The TiPS65 score assigned one point to each of four variables: time to hospital ≤25 minutes, pH value ≥7.0 on initial blood gas assessment, shockable on hospital arrival, and age younger than 65 years. Based on the sum score, the predictive performance for 1-month survival and favorable neurological outcomes, defined as the Cerebral Performance Category 1 or 2, was evaluated.

Results

Among 57,754 patients in the registry, 370 were included in the analysis. The overall one-month survival and favorable neurological outcome were 11.1% (41/370) and 4.2% (15/370), respectively. The 1-month survival rates based on the TiPS65 score were as follows: 11.2% (12/107) for 0 points, 9.3% (14/150) for 1 point, 10.0% (9/90) for 2 points, and 26.1% (6/23) for ≥3 points. Similarly, the 1-month favorable neurological outcomes were: 5.6% (6/107) for 0 points, 2.7% (4/150) for 1 point, 4.4% (4/90) for 2 points, and 4.3% (1/23) for ≥3 points. The area under the curve was 0.535 (95% CI: 0.437-0.630) for 1-month survival and 0.530 (95% CI: 0.372-0.683) for 1-month neurological outcome.

Conclusion

This study demonstrates that the TiPS65 score has limited prognostic performance among OHCA patients with initial non-shockable rhythm treated with ECPR. Further research is warranted to develop a predictive tool specifically focused on OHCA with initial non-shockable rhythm to aid in determining candidates for ECPR.

Role of extracorporeal membrane oxygenation and surgical embolectomy in acute pulmonary embolism

PURPOSE OF REVIEW

Surgery is an important option to consider in patients with massive and submassive pulmonary emboli. Earlier intervention, better patient selection, improved surgical techniques and the use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) have contributed to improve the safety of surgery for pulmonary emboli.

RECENT FINDINGS

VA ECMO is rapidly changing the initial management of patients with massive pulmonary emboli, providing an opportunity for stabilization and optimization before intervention. The early and long-term consequences of acute pulmonary emboli are better understood, in particular with regard to the risks of chronic thromboembolic pulmonary hypertension (CTEPH), an entity that should be identified in the acute setting as much as possible. The presence of chronic thromboembolic pulmonary disease can be associated with persistent haemodynamic instability despite removal of the acute thrombi, particularly if pulmonary hypertension is established. The pulmonary embolism response team (PERT) is an important component in the management of massive and submassive acute pulmonary emboli to determine the best treatment options for each patient depending on their clinical presentation.

SUMMARY

Three types of surgery can be performed for pulmonary emboli depending on the extent and degree of organization of the thrombi (pulmonary embolectomy, pulmonary thrombo-embolectomy and pulmonary thrombo-endarterectomy). Other treatment options in the context of acute pulmonary emboli include thrombolysis and catheter-directed embolectomy. Future research should determine how best to integrate VA ECMO as a bridging strategy to recovery or intervention in the treatment algorithm of patients with acute massive pulmonary emboli.