Circulatory Extracorporeal Membrane Oxygenation Support for High-Risk Acute Pulmonary Embolism

High-risk pulmonary embolism (PE), defined as obstruction of the pulmonary arterial tree that leads to hemodynamic instability, is a common cause of cardiac arrest, with a mortality rate of up to 50%. The obstruction of the pulmonary circulation interferes with gas exchange and causes hemodynamic disturbances in both the right and left sides of the heart. Some international guidelines have suggested the use of extracorporeal membrane oxygenation (ECMO), in combination with definitive therapy, in patients with PE with refractory circulatory collapse or cardiac arrest. Furthermore, several observational studies have shown that ECMO may be beneficial in stabilizing patients with high-risk PE, especially as a form of bridging therapy in patients for whom common reperfusion methods may be insufficient or have delayed efficacy. We present the case of a patient with acute high-risk PE and the role of ECMO in addressing the physiologic derangements caused by PE and improving patient outcomes. We reviewed the literature reporting the experience on ECMO use in conjunction with various forms of definitive treatment for PE. We describe the various ECMO cannulation strategies applicable for patients with high-risk PE, the role of adjunct mechanical circulatory support, practical guidance on ECMO weaning, and the interaction between the PE response team and the ECMO team in the setting of high-risk PE.