Can a patient who receives thrombolysis (thrombolytic therapy) with alteplase (tissue plasminogen activator) for massive pulmonary embolism be put on Extracorporeal Membrane Oxygenation (ECMO) if they do not respond?

ECMO After Thrombolysis for Massive Pulmonary Embolism

ECMO can be used in patients who have received thrombolysis for massive pulmonary embolism if they fail to respond to thrombolytic therapy, as it serves as a rescue therapy for refractory circulatory collapse. 1

Decision Algorithm for ECMO After Thrombolysis

Step 1: Assess Response to Thrombolysis

• Monitor for hemodynamic improvement within 1-2 hours after thrombolysis
• Watch for:
  • Improvement in systolic blood pressure (>90 mmHg without vasopressors)
  • Decreased heart rate
  • Improved oxygenation
  • Signs of adequate tissue perfusion

Step 2: Identify Failure to Respond

• Persistent hypotension despite thrombolysis
• Worsening respiratory failure
• Ongoing signs of cardiogenic shock
• Cardiac arrest or pre-arrest state

Step 3: Consider ECMO Implementation

• ECMO may be considered for patients with massive PE and refractory circulatory collapse or cardiac arrest despite thrombolysis 1
• Venoarterial ECMO (VA-ECMO) is preferred for massive PE with hemodynamic compromise
• Involve a multidisciplinary pulmonary embolism response team (PERT) if available 1

Evidence Supporting ECMO After Thrombolysis

The 2020 European Society of Cardiology (ESC) guidelines explicitly state that ECMO may be considered in combination with surgical embolectomy or catheter-directed treatment in patients with PE and refractory circulatory collapse or cardiac arrest (Class IIb, Level C recommendation) 1. This includes patients who have failed thrombolytic therapy.

Case series have demonstrated successful use of ECMO in patients with massive PE who received thrombolysis but continued to deteriorate 2, 3, 4. In one case series, 62% of patients who ultimately required ECMO had previously received systemic thrombolysis with tPA 2.

Important Considerations and Precautions

Bleeding Risk

• Patients who have received thrombolysis have an increased risk of bleeding complications when placed on ECMO
• Almost all ECMO patients develop acquired von Willebrand syndrome within hours of device implantation 1
• This bleeding diathesis requires careful anticoagulation management

Timing of ECMO

• ECMO should be considered early in patients failing to respond to thrombolysis within the first hour 1
• Delayed implementation may result in irreversible end-organ damage

Contraindications to Consider

• Severe, irreversible brain injury
• Uncontrolled bleeding
• Terminal malignancy with poor prognosis
• Pre-existing severe disability

Post-ECMO Management

• Continue anticoagulation as appropriate
• Consider additional interventions such as catheter-directed therapy or surgical embolectomy once stabilized
• Monitor for ECMO-related complications (bleeding, thrombosis, infection)
• Weaning from ECMO should be considered once hemodynamic stability is achieved and right ventricular function improves

Conclusion

For patients with massive PE who have received thrombolysis but continue to show hemodynamic deterioration, ECMO represents a viable rescue therapy that can stabilize cardiopulmonary function and serve as a bridge to recovery or additional interventions. The decision to implement ECMO should be made rapidly in centers with appropriate expertise to maximize chances of survival.