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首页> 外文期刊>journal of intensive care >Effectiveness of systemic thrombolysis on clinical outcomes in high-risk pulmonary embolism patients with venoarterial extracorporeal membrane oxygenation: a nationwide inpatient database study
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Effectiveness of systemic thrombolysis on clinical outcomes in high-risk pulmonary embolism patients with venoarterial extracorporeal membrane oxygenation: a nationwide inpatient database study

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BackgroundCurrent guidelines recommend systemic thrombolysis as the first-line reperfusion treatment for patients with high-risk pulmonary embolism (PE) who present with cardiogenic shock but do not require venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, little is known about the optimal reperfusion treatment in high-risk PE patients requiring VA-ECMO. We aimed to evaluate whether systemic thrombolysis improved high-risk PE patients' outcomes who received VA-ECMO.MethodsThis was a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2021. We identified patients who were diagnosed with PE and received VA-ECMO on the day of admission. Patients who received systemic thrombolysis with monteplase or urokinase within two days of initiating VA-ECMO were defined as the thrombolysis group and the remaining patients as the control group. The primary outcome was in-hospital mortality and secondary outcomes were favorable neurological outcomes, length of hospital stay, VA-ECMO duration, total hospitalization cost, major bleeding, and blood transfusion volume. Propensity-score inverse probability of treatment weighting (IPTW) was performed to compare the outcomes between the groups.ResultsOf 1220 eligible patients, 432 (35) received systemic thrombolysis within two days of initiating VA-ECMO. Among the unweighted cohort, patients in the thrombolysis group were less likely to have poor consciousness at admission, out-of-hospital cardiac arrest, and left heart catheterization. After IPTW, the patient characteristics were well-balanced between the two groups The crude in-hospital mortality was 52 in the thrombolysis group and 61 in the control group. After IPTW, in-hospital mortality did not differ significantly between the two groups (risk difference: - 3.0, 95 confidence interval: - 9.6 to 3.5). There were also no significant differences in the secondary outcomes. Sensitivity analyses showed a significant difference in major bleeding between the monteplase and control groups (risk difference: 6.9, 95 confidence interval: 1.7 to 12.1), excluding patients who received urokinase. There were no significant differences in the other sensitivity and subgroup analyses except for the total hospitalization cost.ConclusionsSystemic thrombolysis was not associated with reduced in-hospital mortality or increased major bleeding in the high-risk PE patients receiving VA-ECMO. However, systemic thrombolysis with monteplase was associated with increased major bleeding.

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