Extracorporeal Membrane Oxygenation with Right Ventricular Assist Device for COVID-19 ARDS

Abstract

Background: Right ventricular failure is an underrecognized consequence of COVID-19 pneumonia. Those with severe disease are treated with extracorporeal membrane oxygenation (ECMO) but with poor outcomes. Concomitant right ventricular assist device (RVAD) may be beneficial. Methods: A retrospective analysis of intensive care unit patients admitted with COVID-19 ARDS (Acute Respiratory Distress Syndrome) was performed. Non-intubated patients, those with acute kidney injury, and age > 75 were excluded. Patients who underwent RVAD/ECMO support were compared with those managed via invasive mechanical ventilation (IMV) alone. The primary outcome was in-hospital mortality. Secondary outcomes included 30-day mortality, acute kidney injury, length of ICU stay, and duration of mechanical ventilation. Results: A total of 145 patients were admitted to the ICU with COVID-19. Thirty-nine patients met inclusion criteria. Of these, 21 received IMV, and 18 received RVAD/ECMO. In-hospital (52.4 vs 11.1%, p=0.008) and 30-day mortality (42.9 vs 5.6%, p=0.011) were significantly lower in patients treated with RVAD/ECMO. Acute kidney injury occurred in 15 (71.4%) patients in the IMV group and zero RVAD/ECMO patients (p<0.001). ICU (11.5 vs 21 days, p=0.067) and hospital (14 vs 25.5 days, p=0.054) length of stay were not significantly different. There were no RVAD/ECMO device complications. The duration of mechanical ventilation was not significantly different (10 vs 5 days, p=0.44). Conclusions: RVAD support at the time of ECMO initiation resulted in the no secondary end-organ damage and higher in-hospital and 30-day survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support.

Evolving outcomes of extracorporeal membrane oxygenation during the first 2 years of the COVID-19 pandemic: a systematic review and meta-analysis

“…1 , Additional file 1 : Table S4) [ 3 , 5 , 16 – 65 ]. All studies were retrospective and observational in nature; 22 studies were conducted by studies centres from Europe [ 5 , 17 , 19 , 23 , 27 , 29 , 31 – 34 , 36 , 39 , 42 , 43 , 45 , 46 , 50 , 55 , 56 , 60 , 63 , 65 ], 17 from North America [ 16 , 18 , 20 – 22 , 24 , 25 , 37 , 40 , 47 , 48 , 52 – 54 , 57 , 58 , 61 ], 6 from the Asia–Pacific [ 26 , 28 , 35 , 38 , 41 , 44 ], 2 from South-West Asia and Africa,[ 51 , 62 ] 2 from Latin America [ 30 , 64 ], and 3 were studies conducted by centres from multiple ELSO regions [ 3 , 49 , 59 ], of which 2 were based on registry data [ 3 , 49 ]. The pooled age was 52.5 years (95% CI 50.7 to 54.3), and the majority of patients were male (75.0%, 95% CI 72.4% to 77.4%) and obese (BMI: 31.0, 95% CI 30.2 to 31.8).…”

Right Ventricular Failure Manifesting in Corona Virus Disease 2019 Acute Respiratory Distress Syndrome: A Call to Transition from Venovenous Extracorporeal Membranous Oxygenation to Right Ventricular Assist Device Extracorporeal Membranous Oxygenation

“…The advantage of the ProtekDuo TM cannula, in comparison to its competitors, is the insertion within the right IJ vein, permitting full ambulation within recipients. RVAD-ECMO with the ProtekDuo TM in patients with COVID-19 in comparison to mechanical ventilation alone has been to show to reveal no increase in secondary end-organ damage, with higher in-hospital and 30-day survival in the RVAD-ECMO cohort, leading to a conclusion to prioritize RV support in these patients 11 . RVAD-ECMO configuration with the ProtekDuo TM single dual-lumen cannula, in comparison to conventional Crescent TM VV-ECMO circuit in severely ill COVID-19 patients has not yet been studied, though our case showcases there appears to be a benefit through addition of right ventricular support.…”

The Right Ventricle During Veno-Venous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: Can We Protect the Injured Ventricle?

“…33 Veno-pulmonary arterial ECMO led to a threefold survival benefit compared with maximum ventilation support alone and that was observed across all age and body mass index groups. 33 In a small retrospective analysis, Cain et al 35 found that early use of percutaneous RVAD (at the time of ECMO initiation) may improve mortality in patients with severe COVID-19 lung injury. It is possible that early mechanical RV unloading/support in the context of severe acute respiratory failure combined with extracorporeal oxygenation, which allows application of lung- and RV-protective ventilation, accounts for the observed outcome.…”