Algorithm of High-Risk Massive Pulmonary Thromboembolism with Extracorporeal Membrane Oxygenation

Objective: Massive pulmonary embolism (PE) remains a life-threatening condition, often leading to acute respiratory and cardiac failure. This study evaluates the role of extracorporeal membrane oxygenation (ECMO) as a supportive treatment for high-risk patients undergoing surgical pulmonary embolectomy or catheter-based thrombectomy. Methods: Between January 2018 and December 2023, 27 patients with high-risk massive PE were treated at our center. Surgical embolectomy (n = 7) and catheter-based thrombectomy (n = 5) were performed, with ECMO support (veno-arterial [VA] or veno-arterial-venous [VAV]) initiated preoperatively, intraoperatively, or postoperatively, based on hemodynamic instability. ECMO was used as a bridge to recovery, and outcomes were assessed in terms of mortality, hemodynamic stabilization, and recovery. Results: Of the 27 patients, 20 were supported with ECMO, with 7 requiring VA-ECMO intraoperatively due to difficulties in weaning from cardiopulmonary bypass (CPB). Nine patients were later transitioned to VAV-ECMO due to Harlequin syndrome and persistent hemodynamic instability. The in-hospital mortality rate was 18.5% (n = 5), with survivors showing significant improvements in hemodynamic and biochemical parameters post-ECMO, including reduced lactate levels, improved right ventricular function, and the stabilization of mean arterial pressure. The mean follow-up time was 10.2 ± 3.9 months, with no late deaths or complications observed. Conclusions: ECMO provides effective life support in high-risk patients with massive PE who are undergoing surgical embolectomy or thrombectomy. It stabilizes hemodynamics, improves cardiac and pulmonary function, and facilitates recovery in critically ill patients. Further research is needed to refine patient selection, optimize ECMO timing, and assess long-term outcomes to determine its definitive role in the management of high-risk PE.