Reperfusion therapy and outcomes in high-risk pulmonary embolism: A multicenter registry study from the Tokyo Cardiovascular Care Unit Network

Background High-risk pulmonary embolism (PE) carries substantial mortality, but comprehensive real-world data encompassing the entire high-risk population are limited. Reperfusion therapy is recommended for these patients, yet its use in routine practice appears to be less consistent than expected. The present study evaluated current management and outcomes of high-risk PE within the Tokyo Cardiovascular Care Unit (CCU) Network. Methods We analyzed patients with high-risk PE enrolled in the Tokyo CCU Network registry between 2020 and 2022. High-risk PE was defined as shock, sustained hypotension, or cardiac arrest. Reperfusion therapies included systemic thrombolysis, catheter-based therapy, and surgical embolectomy. A multivariable logistic regression model was constructed to identify factors associated with in-hospital mortality. Results Among 1,217 patients with PE, 185 (15.2%) met the criteria for high-risk PE. Reperfusion therapy was performed in 43.8% of these patients (systemic thrombolysis 27.6%, surgical embolectomy 13.0%, catheter-based therapy 3.2%). Venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated in 29.7% of patients. Overall in-hospital mortality was 14.6%. Mortality was lower with reperfusion therapy than without (8.6% vs 19.2%), whereas major bleeding did not differ significantly. In multivariable analysis, cardiac arrest (odds ratio [OR] 3.73, 95% confidence interval [CI] 1.33–10.46), VA-ECMO use (OR 3.08, 95% CI 1.01–8.93), and receipt of reperfusion therapy (OR 0.35, 95% CI 0.12–0.95) were independently associated with in-hospital mortality. Conclusions This study described real-world use and outcomes of reperfusion therapy among patients with high-risk PE within a large regional emergency network. Reperfusion therapy was independently associated with lower in-hospital mortality after adjustment for cardiac arrest and VA-ECMO use. These findings highlight the importance of timely implementation of reperfusion therapy in the modern management of high-risk PE.