VA-ECMO in high-risk pulmonary embolism: outcomes and role as bridge to recovery.

Background: High-risk pulmonary embolism (HRPE) with hemodynamic instability or cardiac arrest carries an in-hospital mortality rate of nearly 30%. VA-ECMO can stabilize acute RV failure and serve as a bridge to therapy or recovery. Due to the heterogeneous utilization of VA-ECMO in HRPE, its ideal application is uncertain. Methods: We retrospectively reviewed 28 HRPE patients meeting ESC/AHA criteria treated with VA-ECMO at a tertiary center (2017-2024). Clinical, procedural, and outcome data were analyzed, with comparisons between survivors and non-survivors to hospital discharge. Results: Mean age was 52 years; 57.1% survived to discharge. Cardiac arrest occurred in 78.6%. Patients with cardiac arrest had similar survival to non-arrest patients (p = 0.673).ECMO was initiated primarily in the catheterization lab (78.6%) and was used similarly between survivors and non-survivors at discharge (p = 0.406). As a bridge to recovery, it was used in 58.3% of non-survivors versus 43.8% of survivors. Mobile ECMO was used in 21.4%, with survival comparable to the overall cohort. Bleeding complications occurred in 82.1% of the patients, most commonly at vascular access sites (65.2%); systemic thrombolysis increased transfusion requirement (p = 0.007) but did not significantly affect survival (p = 0.673). Conclusions: VA-ECMO achieved a 57.1% survival to discharge, consistent with prior studies. No significant survival differences were found between patients with or without cardiac arrest, pre-ECMO thrombolysis, or mobile versus in-hospital ECMO. Thrombolysis increased bleeding without improving outcomes. Mobile ECMO provided rapid support with comparable survival rates. Half the survivors recovered without adjunctive therapies, highlighting ECMO's role as a bridge to recovery. Larger studies are needed to optimize protocols.