The study by Stadlbauer and colleagues provides further evidence that veno-arterial extracorporeal membrane oxygenation (VA-ECMO) should—whenever necessary—be used, as a bridge to pulmonary reperfusion, but not as a bridge to recovery combined with therapeutic anticoagulation alone.

In patients with high-risk pulmonary embolism (PE), the overall goal to minimize morbidity and mortality must be to timely reperfuse the pulmonary vascular bed using the most appropriate reperfusion strategy.

In this issue of the journal, Stadlbauer and colleagues emulated a target trial to investigate in-hospital all-cause mortality in patients with high-risk PE treated with different pulmonary reperfusion strategies or VA-ECMO alone.

They used one of the largest and most comprehensive databases collected from 34 European centers. In their target trial emulation, the principles of a randomized trial design were applied to observational data aimed at estimating the causative effect of different interventions.

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