Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

Background: To examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE). Methods: Following the PRISMA guidelines, a systematic search was conducted up to August 2019 of the databases: PubMed/MEDLINE, EMBASE and Cochrane. All studies reporting the survival of adult patients with acute PE treated with VA-EC MO and including four patients or more were included. Exclusion criteria were: correspondences, reviews and studies in absence of a full text, written in other languages than English or Dutch, or dating before 1980. Short-term (hospital or 30-day) survival data were pooled and presented with relative risks (RR) and 95% confidence intervals (95% CI). Also, the following predefined factors were evaluated for their association with survival in VA-ECMO treated patients: age > 60 years, male sex, pre-EC MO cardiac arrest, surgical embolectomy, catheter directed therapy, systemic thrombolysis, and VA-ECM O as single therapy. Results: A total of 29 observational studies were included (N = 1947 patients: VA-ECM O N = 1138 and control N = 809). There was no difference in short-term survival between VA-EC MO treated patients and control patients (RR 0.91, 95% CI 0.71-1.16). In acute PE patients undergoing VA-ECM O, age > 60 years was associated with lower survival (RR 0.72, 95% CI 0.52-0.99 ), surgical embolectomy was associated with higher survival (RR 1.96, 95% CI 1.39-2.76) and pre-ECMO cardiac arrest showed a trend toward lower survival (RR 0.88, 95% CI 0.77-1. 01). The other evaluated factors were not associated with a difference in survival. Conclusions: At present, there is insufficient evidence that VA-ECMO treatment improves short-term survival of acute PE patients. Low quality evidence suggest that VA-ECMO patients aged <= 60 years or who received SE have higher survival rates. Considering the limited evidence derived from the present data, this study emphasizes the need for prospective studies. Protocol registration: PROSPERO CRD42019120370. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).