Mortality of COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation During the Three Epidemic Waves

Abstract

de dominiCis, ‡ VinCent jounieaux, § pasCal Berna, ¶ herVé dupont,* osama aBou-araB,* and yazine mahjouB* Clinical presentation and mortality of patients treated with extracorporeal membrane oxygenation (ECMO) for COVID-19 acute respiratory distress syndrome (CARDS) were different during the French epidemic waves. The management of COVID-19 patients evolved through waves as much as knowledge on that new viral disease progressed. We aimed to compare the mortality rate through the first three waves of CARDS patients on ECMO and identify associated risk factors. Fifty-four consecutive ECMO for CARDS hospitalized at Amiens University Hospital during the three waves were included. Patients were divided into three groups according to their hospitalization date. Clinical characteristics and outcomes were compared between groups. Pre-ECMO risk factors predicting 90 day mortality were evaluated using multivariate Cox regression. Among 54 ECMO (median age of 61[48-65] years), 26% were hospitalized during the first wave (n = 14/54), 26% (n = 14/54) during the second wave, and 48% (n = 26/54) during the third wave. Time from first symptoms to ECMO was higher during the second wave than the first wave. (17 [12-23] days vs. 11 [9-15]; p < 0.05). Ninety day mortality was higher during the second wave (85% vs. 43%; p < 0.05) but less during the third wave (38% vs. 85%; P < 0.05). Respiratory ECMO survival prediction score and time from symptoms onset to ECMO (HR 1.12; 95% confidence interval [CI]: 1.05-1.20; p < 0.001) were independent factors of mortality. After adjustment, time from symptoms onset to ECMO was an independent factor of 90 day mortality. Changes in CARDS management from first to second waveinduced a later ECMO cannulation from symptoms onset with higher mortality during that wave. The duration of COVID-19 disease progression could be selection criteria for initiating ECMO.

The Right Ventricular Systolic Function Assessment in Adult Respiratory Distress Syndrome: Simple. Basic. Complex.

“…However, other factors, including steroid-resistant disease and changes in clinical management, should not be discarded. 1 Dr. Dandel also suggested that right ventricular (RV) failure may be the primary cause of the high mortality rate of our ECMO patients observed during the second wave. Unfortunately, no precise and objective data supports this hypothesis in our series.…”

“…We thank Dr. Dandel for his interest in our previously published article. 1 We acknowledge that the pathogenicity of dominant SARS-COV-2 "variants of concern" during the second wave (Delta variant) may partially explain the higher mortality observed during the second wave. However, other factors, including steroid-resistant disease and changes in clinical management, should not be discarded.…”

Echocardiography Can Improve the Selection of Mechanical Support Strategies for Patients With Severe COVID-19 Respiratory Distress Syndrome

“…I read with interest the study by Beyls et al . 1 which compared the different clinical characteristics and outcomes of patients with COVID-19–related respiratory distress syndrome (CARDS) requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO) during the three epidemic waves of COVID-19 in France. Despite the increasing knowledge on the particularities of severe COVID-19 and the growing experience in the management of severe CARDS, that study revealed a massive increase in the 90 day mortality of patients undergoing VV-ECMO during the second epidemic wave.…”

“…, Alpha/B.1.1.7, Beta/B.1.351 and Gamma/P.1) and the Omicron/B1.1.529 variant which became the dominant VOC during third wave. 2,3 The excessively high mortality rate ( i.e ., 85.7% 1 ) of patients supported by ECMO during the second wave deserves particular attention because a renewed appearance of more pathogenic VOCs cannot be ruled out.…”

“…Considering the high incidence and the deleterious prognostic impact of right heart involvement in severe COVID-19 it seems likely that this was also the major cause of the high mortality rate documented by Beyls et al . 1 for their ECMO-supported patients (92% with VV-ECMO) during the second wave. Thus, close monitoring of the right heart in patients with CARDS associated with hemodynamic instability, already before overt RV failure develops, could substantially improve therapeutic decision-making.…”