Mechanical Circulatory Support in COVID-19

Circulatory SupportFor COVID-19 patients suffering from myocardial infarction, the limited data available suggest a significantly increased mortality rate, especially for those who require some type of MCS. Data from the NACMI registry showed an almost 60% mortality rate in COVID-19–positive STEMI patients who required MCS, compared with a 30% mortality rate in non-COVID STEMI patients on MCS.Guddeti R.S.C. Jauhar R. Henry T. et al.Mechanical circulatory support in COVID-19 patients presenting with myocardial infarction: Insight from the North American COVID-19 myocardial infarction registry. Submitted. In this registry, 13% of COVID-19–positive STEMI patients received MCS, similar to rates seen in the non-COVID-19 population, highlighting the significant increase in mortality that a concomitant COVID-19 infection conferred. Within the COVID-19 group, the most prevalent type of MCS was the IABP (62%), followed by Impella (28%) and ECMO (7%). Data for or against a particular MCS strategy is limited by the lack of high-quality evidence in the CS patient population. Although the IABP remains commonly used for CS patients requiring MCS, longitudinal data have confirmed that these devices do not confer a mortality benefit.Thiele H. Zeymer U. Thelemann N. et al.Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction. Percutaneous left ventricular assist devices such as the Impella have shown some improvement in small clinical trials and registry data, although the evidence remains mixed and definitive research is ongoing.Acute Cardiovascular Care Association position statement for the diagnosis and treatment of patients with acute myocardial infarction complicated by cardiogenic shock: a document of the Acute Cardiovascular Care Association of the European Society of Cardiology. For these strategies in COVID-19 patients, the data are even more scarce. Case reports exist of using IABPs or Impellas to support hemodynamics in patients with COVID-19 and CS, with mixed outcomes.COVID-19 patient with coronary thrombosis supported with ECMO and Impella 5.0 ventricular assist device: a case report.,Approach to acute cardiovascular complications in COVID-19 infection.VA ECMO for cardiovascular collapse in the COVID-19 population represents the maximal level of support possible and brings with it a high rate of morbidity and mortality—so high, perhaps, that many centers may not offer it in this patient population. Indeed, the Extracorporeal Life Support Organization (ELSO) cautions centers about performing extracorporeal cardiopulmonary resuscitation (defined as the insertion of VA ECMO in patients who are pericardiac arrest) on patients with COVID-19, especially in less experienced centers, because of both the technical complexity of the procedure and the risk of cross-contamination to staff.Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure.For COVID-19 patients requiring cardiac support with VA ECMO, ELSO guidelines suggest judicious patient selection in a multidisciplinary manner. Like all MCS, VA ECMO is not a definitive treatment, but is instead a bridge to a destination, be it recovery, durable ventricular assist device, or transplant. Patients with multisystem organ failure, significant medical comorbidities, or advanced age likely do not benefit from VA ECMO support, even without the added complication of an active COVID-19 infection.Cardiovascular collapse in COVID-19 infection: the Role of Venoarterial extracorporeal membrane oxygenation (VA-ECMO). Some presentations of CS portend slightly better prognoses (eg, myocarditis), whereas other patients with concomitant distributive or inflammatory shock will likely have worse outcomes. On the whole, the decision to place any patient—especially those with an active COVID-19 infection—on VA ECMO should be a thoughtful, team-based decision with a clear exit strategy in mind. Some centers describe an algorithmic approach to MCS in these patients, favoring the initiation of V-A-V ECMO in COVID-19 patients with CS and refractory hypoxemia,Approach to acute cardiovascular complications in COVID-19 infection. although survival rates of this strategy are unknown.Overall, data on outcomes for patients with COVID-19 requiring VA ECMO for CS are extremely limited.Cardiovascular collapse in COVID-19 infection: the Role of Venoarterial extracorporeal membrane oxygenation (VA-ECMO). A large retrospective review of ELSO data found that VA ECMO represents a significant minority of all COVID-19 ECMO cases, perhaps as low as 4%, but is associated with a significantly higher in-hospital mortality rate compared with COVID-19 patients on VV ECMO.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. ELSO itself does not directly report COVID-19 VA ECMO survival on its public dashboard, but at the time of publication, the survival rate to discharge in the COVID-19 non-ARDS adult cohort is less than 10%.Registry dashboard of ECMO-supported COVID-19 patient data. 2/18/22]. The EuroELSO survey of adult COVID-19 patients in Europe demonstrates a significant decline in the application of VA ECMO in this patient population as the pandemic has progressed, with VA ECMO representing 9% of all COVID-19 ECMO cases at the onset of the pandemic, but falling to an average of 4% during the fourth wave.EuroELSO Survey on ECMO use in adult COVID-19 patients in Europe. 2/18/22].The remainder of our current data is limited to case series and case reports, most of which report significant mortality rates for VA ECMO in COVID-19, far above prepandemic benchmarks.ECMO therapy in COVID-19: an experience from Zurich. Although more information is certainly needed about this patient population to guide thoughtful application and patient selection, it can be said that mortality rates for COVID-19 patients requiring any degree of MCS are high, and VA ECMO portends an even higher risk of death. Centers and clinicians who choose to pursue any MCS strategy in COVID-19 patients must do so thoughtfully and selectively, understanding the inherent risks and resources required.Respiratory SupportFor patients with severe acute respiratory distress syndrome (ARDS), be it from COVID-19 or another pulmonary insult, VV ECMO remains a salvage and off-label therapy for lung rescue for certain patient populations. The largest randomized controlled trial investigating VV ECMO for severe ARDS, conducted in the pre-COVID-19 era, was technically a negative trial,Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. although meta-analyses have shown some benefit for VV ECMO for refractory ARDS,Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. and subsequently its use in the adult population has increased significantly over the past 20 years. Although there are no universal guidelines, inclusion criteria from the EOILA trial are often used to evaluate VV ECMO candidacy, and include a Pao2:Fio2 ratio of less than 50 mm Hg despite maximal medical therapy for ARDS or a refractory respiratory acidosis.Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. According to the ELSO registry, ARDS patients requiring VV ECMO in 2018 had an overall survival rate of approximately 62%.Extracorporeal Life Support Organization
ECLS registry report international summary. It is understandable, then, that VV ECMO posed an attractive option for patients with severe COVID-19–related ARDS at the beginning of the pandemic, when initial data suggested an up to 97% 28-day mortality rate for intubated COVID-19 patients.Clinical Course and outcomes of 344 intensive care patients with COVID-19. After the first wave, some initial registry data were encouraging: mortality for COVID-19 patients on VV ECMO was less than 40%, which was in line with prepandemic outcomes.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. However, much of that initial enthusiasm has been since tempered, as subsequent waves of the pandemic have shown diminishing returns from the application of VV ECMO in this patient population. Registry data revealed a significant increase in mortality as the pandemic has progressed: after May 2020, mortality for this cohort rose above 50%.Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international extracorporeal Life support Organization registry. Although the underlying reasons for this decline remain somewhat unclear, the available evidence does suggest some possible etiologies.As the pandemic progressed, more centers with less overall ECMO experience began offering VV ECMO to COVID-19 patients. Registry data did show that hospitals with less ECMO experience witnessed higher mortality rates than more experienced ECMO centers,Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international extracorporeal Life support Organization registry. potentially underscoring the challenges of expanding a complex technology to centers with less volume or training. A recent observational study showed an increased risk of mortality for patients cannulated at a nonspecialized center.Gannon W.D. Stokes J.W. Francois S.A. et al.Association between availability of ECMO and mortality in COVID-19 patients eligible for ECMO: a natural experiment. In addition, improved medical management of COVID-19 patients, including the use of systemic steroids and antiviral agents together with improved noninvasive oxygenation and ventilation strategies,Dexamethasone in hospitalized patients with covid-19.Remdesivir for the treatment of Covid-19 - final report.Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies. may have led to a sicker, “nonresponder” phenotype of patients being referred for VV ECMO. Although previous VV ECMO studies for ARDS patients had clear inclusion criteria—including, for example, less than 7 days of invasive ventilationExtracorporeal membrane oxygenation for severe acute respiratory distress syndrome.—the COVID-19 pandemic challenged these norms. As more patients languished on noninvasive ventilation for weeks before intubation, identifying a cohort of patients who would benefit from VV ECMO has become increasingly challenging. Although avoiding ventilator-induced lung injury is a well-known concept in modern ARDS management and remains the ultimate goal of the “lung rest” afforded by VV ECMO,Slutsky A.S. Ranieri V.M. Ventilator-induced lung injury. non–ventilator-associated barotrauma and patient-induced lung injury are not as clearly defined and are ongoing areas of research.Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Although some treatment strategies may decrease the number of COVID-19 patients who progress to severe ARDS, there is a real risk of delaying recognition of the cohort of patients who are actively declining with respect to their respiratory disease and are within the window to benefit from VV ECMO. Patients who presented with evidence of barotrauma before intubation, for example, posed challenges to ECMO teams—would these patients receive any benefit from the “lung rest” of VV ECMO?—, and many centers adopted more restrictive VV ECMO inclusion criteria for COVID-19 patients as the pandemic progressed.Gannon W.D. Stokes J.W. Francois S.A. et al.Association between availability of ECMO and mortality in COVID-19 patients eligible for ECMO: a natural experiment. Some centers applied a more aggressive strategy of earlier VV ECMO cannulation: one small retrospective study showed lower mortality rates with early VV ECMO use, and a significantly lower mortality rate of 25% for patients who were cannulated before intubation.Clinical outcomes of severe COVID-19 patients receiving early VV-ECMO and the impact of pre-ECMO ventilator use.However, VV ECMO remains a technically challenging and personnel-intensive limited resource, with significant risks associated with its use, and clear guidelines on how and when to apply this technology to COVID-19 patients remain unclear.Extracorporeal membrane oxygenation for COVID-19: Updated 2021 guidelines from the extracorporeal Life support Organization. Unfortunately, most of the data on VV ECMO during COVID-19 comes from retrospective studies, case series, and international registries, which lack control groups or randomization, and are often subject to reporting bias. The heterogeneity between survivors and nonsurvivors of ARDS following COVID-19 is becoming clearer, but the scientific community continues to lack the ability to reliably predict which patients may benefit from VV ECMO and in what manner that technology should be applied. As the body of evidence in this patient population grows, institutions must remain flexible about applying clear inclusion criteria for these patients which reflect best practices for VV ECMO but also take into consideration the resources of the institution or region, as this can significantly impact mortality rates as well.Gannon W.D. Stokes J.W. Francois S.A. et al.Association between availability of ECMO and mortality in COVID-19 patients eligible for ECMO: a natural experiment. Further studies are needed to focus on defining and identifying severe ARDS phenotypes to better assess the efficacy of such a resource-intensive technology as VV ECMO.

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