What is the management approach for a patient with pulmonary embolism (PE) requiring Veno-Venous (VV) Extracorporeal Membrane Oxygenation (ECMO)?

VV-ECMO for Pulmonary Embolism: Management Approach

VV-ECMO is NOT the appropriate ECMO configuration for pulmonary embolism—VA-ECMO (veno-arterial) should be used instead, as PE causes hemodynamic collapse requiring both cardiac and respiratory support, not isolated respiratory failure. 1

Critical Distinction: ECMO Configuration Selection

VA-ECMO is the Standard for PE

• VA-ECMO provides both cardiac and pulmonary support, which is essential for PE patients with circulatory collapse or cardiac arrest 1
• The 2019 ESC Guidelines specifically recommend ECMO (referring to VA-ECMO) may be considered in combination with surgical embolectomy or catheter-directed treatment in refractory circulatory collapse or cardiac arrest 1
• VA-ECMO is the principal configuration for massive PE, used in approximately 61% of ECMO-supported PE cases in registry data 2

VV-ECMO Has Limited Role

• VV-ECMO only provides respiratory support (oxygenation and CO2 removal) without hemodynamic support 1, 3
• VV-ECMO can be applied in highly selected PE cases where patients are hemodynamically stable but require aggressive ventilation support, representing only 39% of ECMO-supported PE cases 2
• If a patient truly requires ECMO for PE, they almost always need hemodynamic support, making VA-ECMO the correct choice 2, 4

Management Algorithm for High-Risk PE Requiring ECMO

Immediate Stabilization (Minutes 0-30)

• Initiate VA-ECMO emergently for patients with refractory circulatory collapse, cardiac arrest, or pulseless electrical activity from massive PE 1
• Begin unfractionated heparin intravenously with weight-adjusted bolus without delay 5
• Administer norepinephrine (0.2-1.0 mcg/kg/min) to maintain systemic blood pressure and coronary perfusion gradient 1
• Consider dobutamine (2-20 mcg/kg/min) if cardiac index is low with normal blood pressure, though this may worsen hypotension if used alone 1

Anticoagulation During ECMO Support

• Continue systemic anticoagulation with unfractionated heparin during ECMO support, as the circuit itself requires anticoagulation to prevent thrombosis 1
• Monitor anticoagulation carefully, as 42% of VV-ECMO patients experience thrombotic events and 37% experience bleeding complications 1
• The competing risks of circuit thrombosis versus life-threatening bleeding require vigilant monitoring 1

Definitive Therapy Selection (Hours 1-72)

Use VA-ECMO as a bridge to optimize end-organ function and triage to appropriate definitive therapy 4:

• Continue ECMO support until organ optimization is achieved (typically median 5.1 days) 4
• Assess residual thrombus burden, RV function recovery, and neurologic status to determine next steps 4

If thrombus burden resolves with anticoagulation alone:

• Decannulate ECMO once RV function normalizes (occurs in approximately 40% of cases) 4

If substantial clot burden persists with RV strain:

• Surgical pulmonary embolectomy is recommended for high-risk PE when thrombolysis is contraindicated or has failed 1
• Combining ECMO with surgical embolectomy yields excellent outcomes: 93% in-hospital survival and 91% one-year survival in recent series 1
• Catheter-directed therapy should be considered as an alternative when surgery is not feasible 1

Multidisciplinary Team Activation

• Activate a Pulmonary Embolism Response Team (PERT) immediately for high-risk PE cases 1
• The team should include cardiology, pulmonology, intensive care, cardiothoracic surgery, and interventional radiology 1
• Real-time multidisciplinary decision-making optimizes treatment selection and implementation 1

Configuration Transition Considerations

VAV-ECMO (Veno-Arterial-Venous)

• Transition from VA to VAV-ECMO if Harlequin syndrome develops (differential oxygenation with hypoxemia in upper body) 6
• This occurred in 45% of patients in one series who initially received VA-ECMO 6
• VAV configuration provides additional venous drainage to improve oxygenation 6

Common Pitfalls to Avoid

Do not use VV-ECMO as first-line for hemodynamically unstable PE:

• VV-ECMO cannot provide the circulatory support needed for shock or cardiac arrest 2, 4
• Patients requiring mechanical resuscitation had VA-ECMO in 83% of cases versus 38% for VV-ECMO 2

Do not delay definitive therapy:

• ECMO is a bridge, not destination therapy 4
• Survival to discharge is similar (45-48%) regardless of ECMO configuration when appropriate therapy follows 2

Do not use systemic thrombolysis routinely in intermediate or low-risk PE:

• Thrombolysis is reserved for high-risk PE with hemodynamic instability 1
• Recent surgery or trauma (as in many PE cases) represents an absolute contraindication to thrombolysis 7

Outcomes with Protocolized Approach

• In-hospital survival of 95% and 90-day survival of 95% achieved with aggressive VA-ECMO protocol for massive PE 4
• 95% of survivors had normal RV function at discharge 4
• Overall survival to discharge ranges from 44-49% across different series 2