C48-28 Difficult Decisions When Evaluating the Patient Candidate for Support With Extracorporeal Oxygen Therapy

Abstract Rationale Extracorporeal Membrane Oxygenation (ECMO) therapy is used in patients with refractory cardiogenic shock and/or severe respiratory failure. Although the experience and training of multidisciplinary shock teams have improved survival outcomes, accurate patient selection remains critical to achieving favorable results. Predictive models could assist in identifying which patients would benefit from ECMO therapy; however, currently available models have shown limited predictive performance. Case description We present the case of a 62-year-old man with a history of stage IIb lung adenocarcinoma, organizing pneumonia secondary to immunotherapy, and a past history of smoking. He underwent a right upper lobectomy with lymph node dissection via thoracoscopy. Ten days postoperatively, he presented to the emergency department with dyspnea and oxygen desaturation (SpO2 65%). A chest CT angiogram revealed a massive pulmonary embolism (PE) involving the main pulmonary artery trunk and bilateral segmental branches. Echocardiography showed a left ventricular ejection fraction of 62%, a dilated right ventricle with decreased systolic function, pulmonary hypertension, severe hypoxemia (Pa/Fi 119), respiratory acidosis (pH 7.01, PaCO2 75), and hyperlactatemia. Due to a recent surgery, systemic thrombolysis was contraindicated, and he underwent mechanical thrombectomy.During the procedure, he suffered three cardiac arrests (ventricular fibrillation and pulseless electrical activity), each brief and followed by return of spontaneous circulation. He subsequently developed cardiogenic shock (SCAI stage E), refractory hypoxemia, and acute kidney injury, requiring inotropic and vasopressor support. The ECMO team was consulted; the RESP and SAVE scores predicted survival probabilities of 33% and 42%, respectively. Despite relative contraindications—recent surgery, malignancy, and uncertain prognosis—the multidisciplinary team concluded that ECMO could be beneficial. Veno-pulmonary ECMO was initiated on August 25, 2023, and maintained until September 23, 2023, complicated mainly by infections and coagulopathy. After five months of hospitalization, the patient was discharged without neurological deficits and remains alive as of 2025. Conclusion Assessing the appropriateness of initiating a high-cost therapy such as ECMO, given its considerable mortality, complications, and uncertain prognosis, represents a major ethical and clinical challenge. In pulmonary embolism, no single prognostic tool exists; instead, risk stratification depends on a combination of clinical factors, ECMO-related scores, and PE-specific risk scales, none validated for ECMO use. In this case, timely thrombectomy, witnessed short-duration arrests with favorable rhythms, and a potentially curative prior surgery justified the decision to proceed with ECMO as a bridge to recovery, ultimately with successful outcome. This abstract is funded by: None