The role of veno-arterial extracorporeal membrane oxygenation (ECMO) remains ill defined in patients with high-risk pulmonary embolism (PE). We investigated the outcomes in patients with high-risk PE undergoing ECMO according to the initial therapeutic strategy.

Patients from 9 centres with high-risk PE undergoing ECMO for cardiac arrest or persistent shock were included. We compared patients according to treatment strategy (systemic thrombolysis, surgical embolectomy, or no reperfusion therapy). The primary outcome was all-cause 30-day mortality. Secondary outcomes were successful weaning from ECMO and major bleeding.

From January 2014 to December 2015, 52 patients (mean age 47.6 years) underwent ECMO for refractory cardiogenic shock (n=13, 25%) and cardiac arrest (n=39, 75%), of whom 18 (46%) had ECMO initiated during cardiopulmonary resuscitation. Overall 30-day mortality was 61.5% (32/52): 76.5% (13/17) in patients treated with fibrinolysis, 29.4% (5/17) in patients treated with surgical embolectomy, and 77.8% (14/18) in patients who received ECMO alone (P=0.004). Nineteen (36.5%) patients were successfully weaned from ECMO (5/17 (29.4%) in patients with fibrinolysis; 11/17 (64.7%) in patients with surgical embolectomy, 3/18 (17.7%) in patients with ECMO alone, P=0.009). Twenty patients (38.5%) had a major bleeding event in-hospital; without significant difference across groups.

Mortality is high in PE patients with ECMO, especially in those undergoing fibrinolysis and in those with no reperfusion. Life-support therapy with ECMO should not be considered as a stand-alone treatment strategy in high risk PE patients, but shows promise as a complement to surgical embolectomy.