Reperfusion Therapy and Outcomes in High-Risk Pulmonary Embolism: Multicenter Registry Study From the Tokyo Cardiovascular Care Unit Network.

Background: High-risk pulmonary embolism (PE) is associated with substantial mortality, and contemporary guidelines recommend prompt reperfusion therapy when feasible. However, real-world data describing how reperfusion is used in practice, and its outcomes, remain limited. Methods and Results: We conducted an observational analysis of patients with high-risk PE enrolled in the Tokyo Cardiovascular Care Unit Network registry between 2020 and 2022. High-risk PE was defined as a presentation complicated with shock, sustained hypotension, or cardiac arrest. Reperfusion therapies included systemic thrombolysis, catheter-based therapy, and surgical embolectomy. Of 1,217 patients with PE, 185 (15.2%) met the high-risk PE criteria. Reperfusion therapy was administered to 43.8% of patients (systemic thrombolysis, 27.6%; surgical embolectomy, 13.0%; catheter-based therapy, 3.2%), and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was used in 29.7% of patients. Overall, in-hospital mortality was 14.6%. Mortality was lower with than without reperfusion therapy (8.6% vs. 19.2%), without significant differences in bleeding events. In multivariable logistic regression analysis, cardiac arrest, VA-ECMO use, and lack of reperfusion therapy were independently associated with increased in-hospital mortality risk. Conclusions: In this contemporary multicenter registry, reperfusion therapy was used in fewer than half of patients with high-risk PE and was associated with lower in-hospital mortality, although residual confounding cannot be excluded given the observational study design. These findings highlight both the potential benefit and the incomplete real-world adoption of guideline-recommended reperfusion strategies.