COVID‐19, ECMO, and respiratory infection: A new triad?

Abstract

In December 2019, the initial outbreak of COVID-19 started in Wuhan, China, which rapidly escalated to an international scale within weeks. 1 This ultimately resulted in it being declared as a global pandemic by the World Health Organization (WHO) in March 2020. 2 This highly contagious respiratory infection has since mutated and evolved to enable viral survival in the host. 3 Treatment pathways for the virus have also changed and improved, accompanied by more knowledge of the disease pathogenesis. For example, May 2020 saw the introduction of the broad-spectrum antiviral medication Remdesivir, followed by the FDA's approval of monoclonal antibodies such as Bamlanivimab in November 2020. 4 The employment of extracorporeal membrane oxygenation (ECMO) as supportive therapy for COVID-19-related ARDS has also been advocated for by the WHO and Extracorporeal Life Support Organization (ELSO). 5 This rescue therapy 6 is primarily recommended as a last resort, subsequent to unavailing results from conventional therapies 7 for COVID-19 patients with a limited number of co-morbidities who do not have severe multisystem organ failure. 8 Yet, according to the ELSO Registry, the in-hospital mortality rate remains as high as 47%. 9 This sparks some questions on the use of this therapy in COVID-19 patients with ARDS. Whilst there are some studies to suggest the clinical benefit of ECMO, 10 there is also concern over potential increased mortality and morbidity of up to 65% in some cases. 11

COVID-19 and Multiorgan Response: The Long-Term Impact

“…For severe acute respiratory distress syndrome (ARDS), prone ventilation for 16 hours/day is suggested 79 . Additional rescue interventions include extracorporeal membrane oxygenation (ECMO) 80 , 108 , 109 .…”

Understanding outcomes of emergency aortic dissection repair during COVID‐19 pandemic: What lessons have we learnt?

“… 9 A study by Shih et al demonstrated a higher rate of secondary coinfections in COVID‐19 positive patients with ARDS following extracorporeal membrane oxygenation placement, suggesting limited benefit of this rescue therapy. 10 This advocated for a standardized and documented approach to manage an ATAAD, where evidence is slowly growing on the optimal surgical approach, such as on the efficacy of valve‐sparing root replacement in ATAAD repairs. 11 A study from Wang et al alternatively provided insight into the use of triple branched stent graft implantation for ATAAD.…”

“…For example, SARS‐CoV‐2 infection has shown to exacerbate arrhythmias, acute coronary syndrome, and thromboembolism 9 . A study by Shih et al demonstrated a higher rate of secondary coinfections in COVID‐19 positive patients with ARDS following extracorporeal membrane oxygenation placement, suggesting limited benefit of this rescue therapy 10 . This advocated for a standardized and documented approach to manage an ATAAD, where evidence is slowly growing on the optimal surgical approach, such as on the efficacy of valve‐sparing root replacement in ATAAD repairs 11 .…”