COVID-19 outcomes of venovenous extracorporeal membrane oxygenation for acute respiratory failure vs historical cohort of non-COVID-19 viral infections

Abstract

Introduction Veno-venous extracorporeal membrane oxygenation (VV ECMO) has become a support modality for patients with acute respiratory failure refractory to standard therapies. VV ECMO has been increasingly used during the current COVID-19 pandemic for patients with refractory respiratory failure. The object of this study was to evaluate the outcomes of VV ECMO in patients with COVID-19 compared to patients with non-COVID-19 viral infections. Methods We retrospectively reviewed all patients supported with VV ECMO between 8/2014 and 8/2020 whose etiology of illness was a viral pulmonary infection. The primary outcome of this study was to evaluate in-hospital mortality. The secondary outcomes included length of ECMO course, ventilator duration, hospital length of stay, incidence of adverse events through ECMO course. Results Eighty-nine patients were included (35 COVID-19 vs 54 non-COVID-19). Forty (74%) of the non-COVID-19 patients had influenza virus. Prior to cannulation, COVID-19 patients had longer ventilator duration (3 vs 1 day, p = .003), higher PaCO2 (64 vs 53 mmHg, p = .012), and white blood cell count (14 vs 9 ×103/μL, p = .004). Overall in-hospital mortality was 33.7% ( n = 30). COVID-19 patients had a higher mortality (49% vs. 24%, p = .017) when compared to non-COVID-19 patients. COVID-19 survivors had longer median time on ECMO than non-COVID-19 survivors (24.4 vs 16.5 days p = .03) but had a similar hospital length of stay (HLOS) (41 vs 48 Extracorporeal Membrane Oxygenationdays p = .33). Conclusion COVID-19 patients supported with VV ECMO have a higher mortality than non-COVID-19 patients. While COVID-19 survivors had significantly longer VV ECMO runs than non-COVID-19 survivors, HLOS was similar. This data add to a growing body of literature supporting the use of ECMO for potentially reversible causes of respiratory failure.

Outcomes of patients with coronavirus disease versus other lung infections requiring venovenous extracorporeal membrane oxygenation

“…Nonetheless, patients with COVID-19 spent significantly longer periods of time on MV before ECMO cannulation (6.5 (2.0–11.0) days) with lower but still high respiratory pressures. Dave et al also reported the difference in the length of MV in patients with COVID-19 vs patients with other viral pneumonia before ECMO, which were shorter as in our study (1.0 (0.25–3.0) vs 3.0 (1.5–4.5) days) [ 20 ]. Barbaro et al reported MV before ECMO in COVID-19 patients in 4.3 (2.0–6.5) days, whereas in the study by Widmeier et al in Germany, it was 7.8 (4–12.7) days.…”

“…In studies from Germany and France, the overall 90-day mortality was 52–68%, again depending on the wave of the pandemic [ 22 , 23 ]. Barbaro and Dave demonstrated better survival in patients with COVID-19 compared with reports from France and Germany (including our results), apparently due to better patient selection; the average age in the first reports was 47–50 years compared to 59–61 in other reports [ [20] , [21] , [22] , [23] ]. In addition, the group studied by Dave et al did not include patients with ischemic heart disease; Barbaro et al reported that only 3–5% of patients had a pre-existing heart disease in the COVID-19 group [ 20 , 21 ], whereas 21.1% of patients with COVID-19 in our study had pre-existing ischemic heart disease.…”

“…Barbaro and Dave demonstrated better survival in patients with COVID-19 compared with reports from France and Germany (including our results), apparently due to better patient selection; the average age in the first reports was 47–50 years compared to 59–61 in other reports [ [20] , [21] , [22] , [23] ]. In addition, the group studied by Dave et al did not include patients with ischemic heart disease; Barbaro et al reported that only 3–5% of patients had a pre-existing heart disease in the COVID-19 group [ 20 , 21 ], whereas 21.1% of patients with COVID-19 in our study had pre-existing ischemic heart disease. In all these studies including ours, 73–83% of patients were male; male sex was an important driver of mortality risk in all patients with COVID-19, due to hormonal, inflammatory, immunological, and phenotypic differences, and severe disease patterns [ 24 ].…”

“…Only a few reports have compared patients with COVID-19 on ECMO to patients with other infectious diseases on ECMO. Dave et al also reported a higher mortality in COVID-19 (49% vs. 24%, p = 0.017), when compared to other viral infections [ 20 ]. Most of studies have compared COVID-19 patients on V–V ECMO to each other during different pandemic waves.…”

New and personalized ventilatory strategies in patients with COVID-19

“…Some studies compared ECMO in non-COVID-ARDS patients and COVID-ARDS patients. Although similar results were gathered about oxygenation (99,100), the treatment time and complications were different. Chandel et al (99) analyzed 9,271 patients who required ECMO between 2017 and 2021.…”