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Comparative Study
. 2021 Aug:264:81-89.
doi: 10.1016/j.jss.2021.03.017. Epub 2021 Mar 18.

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

Michael T Cain  1 , Nathan J Smith  2 , Mark Barash  3 , Pippa Simpson  4 , Lucian A Durham 3rd  1 , Hemanckur Makker  5 , Christopher Roberts  5 , Octavio Falcucci  5 , Dong Wang  6 , Rebekah Walker  7 , Gulrayz Ahmed  8 , Sherry-Ann Brown  9 , Rahul S Nanchal  3 , David L Joyce  10
Affiliations
Comparative Study

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

Michael T Cain et al. J Surg Res. 2021 Aug.

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. Nonintubated 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-d 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 versus 11.1%, P = 0.008) and 30-d mortality (42.9 versus 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 versus 21 d, P= 0.067) and hospital (14 versus 25.5 d, 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 versus 5 d, 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-d survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support.

Keywords: Acute respiratory distress syndrome; COVID-19; Extracorporeal membrane oxygenation; Right ventricular assist device.

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Figures

Fig 1
Fig. 1
COVID-19 ICU cohort flow diagram. All patients admitted to the ICU were considered excluding patients based on specified exclusions criteria. Those with severe ARDS were considered in the final cohort and divided in those who received RVAD/ECMO and those treated with mechanical ventilation alone. ARDS = acute respiratory distress syndrome; ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit; RVAD = right ventricular assist device; VV = venovenous.
Fig 2
Fig. 2
RVAD/ECMO specific outcomes. The TandemLife Protek Duo is a percutaneous right ventricular assist device (RVAD) which is inserted into the right internal jugular vein. Inflow to the extracorporeal circuit occurs via the outer, which is positioned in the right atrium, while outflow to the pulmonary artery occurs via the inner lumen. ECMO = extracorporeal membrane oxygenation.
Fig 3
Fig. 3
Kaplan-Meier cumulative mortality between RVAD/ECMO and IMV-alone. IMV = invasive mechanical ventilation; RVAD/ECMO, right ventricular assist device/extracorporeal membrane oxygenation.
See this image and copyright information in PMC

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