David A. Baran, MD, FACC, FSCAI, FHFSA, and Hannah Copeland, MD
Central Message.
Interest is increasing in the use of rescue venovenous extracorporeal membrane oxygenation to treat patients with COVID-19 infection. Careful patient selection and preparation for lengthy support times are imperative.
See Article page 1071.
Before the current COVID-19 crisis, there was the H1N1 influenza pandemic in 2009.1 , 2 This pathogen was associated with a high incidence of severe respiratory failure, and in that setting, use of veno-veno extracorporeal membrane oxygenation (VV-ECMO) became much more common in expert centers.3, 4, 5 The majority of injuries from H1N1 were respiratory, although other effects were noted. Now, 11 years later, the world is battling the SARS-CoV2 virus and COVID-19. Naturally, the inclination is to examine previous strategies, in particular VV-ECMO.
In this issue of the Journal, Shih and DiMaio6 report the use of VV-ECMO in patients with COVID-19–related respiratory failure patients in a large US health care system. Their cohort comprised 37 patients with proven COVID-19 and respiratory failure who underwent VV-ECMO support at 4 centers in their health care system. These patients represented 1.4% of the 2557 patients who were hospitalized with COVID-19 and 12.5% of the 320 who were intubated. The strengths of this report include a uniform approach to patient management and strict criteria for using VV-ECMO across centers, as well as a full reporting of the outcomes. More than one-half of the patients survived to discharge (56.8%), but most were either sent back to the referring facility or transferred to a long-term acute care facility for ventilator weaning. Only 7 of 37 (18.9%) were able to go home directly, and there is no information on the postdischarge outcomes.
Clearly, COVID-19 is a multisystem illness, and using the same playbook as that used for the H1N1 pandemic will not suffice. The SARS-CoV2 virus is quite infectious, and the number of cases is staggeringly large. In addition to cardiac damage,7 hypercoagulability,8 neurologic issues9 and others, this disease can result in irreversible lung damage necessitating lung transplantation. The experience with COVID ECMO is in sharp contrast to the H1N1 experience, where mortality was approximately 21% in one large study.3
A few points should be emphasized. First, patient selection is one of the most important aspects of an ECMO program. COVID patients must be screened carefully for other organ system dysfunction, including those that develop as a result of the viral infection. In the current report, ECMO was withdrawn for futility in 35.1% of patients, despite strict screening for candidacy. Perhaps with further research, we will be able to develop scoring systems specific to COVID respiratory failure to help teams avoid futile care.
Second, the program must be prepared for lengthy intensive care unit (ICU) stays and the associated resource requirements. In this report, the median ICU length of stay was 31 days among survivors, with a median total hospital length of stay of 44 days. This is similar to other ECMO experiences,4 , 5 , 10 , 11 and thus hospitals need to consider the availability of ICU beds when committing to supporting a COVID patient with VV ECMO.2 , 12
Finally, there are recent unpublished reports of lung transplantation in COVID patients who cannot be weaned from support.13 Transplantation may be an option for a rare subset of patients, but it will be important for ECMO centers to partner with those groups offering such high-risk lung transplants to appropriately identify candidates for this therapy.
In the end, however, VV ECMO and lung transplant are very limited and precious resources. The majority of critically ill patients with COVID-19–related refractory respiratory failure will die, and even those who are rescued with VV-ECMO face a daunting gauntlet to overcome. With <20% of patients recuperating sufficiently to be directly discharged to home following ECMO support, we need to allocate these resources in a very focused fashion. Most patients with COVID-19 will remain a long way from home.
Footnotes
Disclosures: Dr Baran has consulted for Getinge, LivaNova, Abiomed, and Abbott; has spoken for Pfizer; and serves on steering committees for Procyrion and CareDx. Dr Copeland has served as a consultant for Bridge to Life and Paragonix.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
References
- 1.Kumar A., Zarychanski R., Pinto R., Cook D.J., Marshall J., Lacroix J., et al. Critically ill patients with 2009 influenza A(H1N1) infection in Canada. JAMA. 2009;302:1872–1879. doi: 10.1001/jama.2009.1496. [DOI] [PubMed] [Google Scholar]
- 2.Hubmayr R.D., Farmer J.C. Should we “rescue” patients with 2009 influenza A(H1N1) and lung injury from conventional mechanical ventilation? Chest. 2010;137:745–747. doi: 10.1378/chest.09-2915. [DOI] [PubMed] [Google Scholar]
- 3.Davies A., Jones D., Bailey M., Beca J., Bellomo R., Blackwell N., et al. Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome. JAMA. 2009;302:1888–1895. doi: 10.1001/jama.2009.1535. [DOI] [PubMed] [Google Scholar]
- 4.Chan K.K., Lee K.L., Lam P.K., Law K.I., Joynt G.M., Yan W.W. Hong Kong's experience on the use of extracorporeal membrane oxygenation for the treatment of influenza A (H1N1) Hong Kong Med J. 2010;16:447–454. [PubMed] [Google Scholar]
- 5.Freebairn R., McHugh G., Hickling K. Extracorporeal membrane oxygenation for ARDS due to 2009 influenza A(H1N1) JAMA. 2010;303:941–942. doi: 10.1001/jama.2010.201. author reply 942. [DOI] [PubMed] [Google Scholar]
- 6.Shih E., DiMaio J.M., Squiers J.J., Banwait J.K., Meyer D.M., George T.J., et al. Venovenous extracorporeal membrane oxygenation for patients with refractory Coronavirus disease 2019 (Covid-19): multicenter experience of referral hospitals in a large healthcare system. J Thorac Cardiovasc Surg. 2022;163:1071–1079.e3. doi: 10.1016/j.jtcvs.2020.11.073. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Fried J.A., Ramasubbu K., Bhatt R., Topkara V.K., Clerkin K.J., Horn E., et al. The variety of cardiovascular presentations of COVID-19. Circulation. 2020;141:1930–1936. doi: 10.1161/CIRCULATIONAHA.120.047164. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Terpos E., Ntanasis-Stathopoulos I., Elalamy I., Kastritis E., Sergentanis T.N., Politou M., et al. Hematological findings and complications of COVID-19. Am J Hematol. 2020;95:834–847. doi: 10.1002/ajh.25829. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Waldman G., Mayeux R., Claassen J., Agarwal S., Willey J., Anderson E., et al. Preparing a neurology department for SARS-CoV-2 (COVID-19): early experiences at Columbia University Irving Medical Center and the New York Presbyterian Hospital in New York City. Neurology. 2020;94:886–891. doi: 10.1212/WNL.0000000000009519. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Freed D.H., Henzler D., White C.W., Fowler R., Zarychanski R., Hutchison J., et al. Extracorporeal lung support for patients who had severe respiratory failure secondary to influenza A (H1N1) 2009 infection in Canada. Can J Anaesth. 2010;57:240–247. doi: 10.1007/s12630-009-9253-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Noah M.A., Peek G.J., Finney S.J., Griffiths M.J., Harrison D.A., Grieve R., et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1) JAMA. 2011;306:1659–1668. doi: 10.1001/jama.2011.1471. [DOI] [PubMed] [Google Scholar]
- 12.Dalton H.J., MacLaren G. Extracorporeal membrane oxygenation in pandemic flu: insufficient evidence or worth the effort? Crit Care Med. 2010;38:1484–1485. doi: 10.1097/CCM.0b013e3181e08fff. [DOI] [PubMed] [Google Scholar]
- 13.Chen J.Y., Qiao K., Liu F., Wu B., Xu X., Jiao G.Q., et al. Lung transplantation as therapeutic option in acute respiratory distress syndrome for coronavirus disease 2019-related pulmonary fibrosis. Chin Med J (Engl) 2020;133:1390–1396. doi: 10.1097/CM9.0000000000000839. [DOI] [PMC free article] [PubMed] [Google Scholar]