ABSTRACT
Background: Evidence of cerebrovascular complications in Coronavirus disease 2019 (COVID-19) requiring veno-venous extracorporeal membrane oxygenation (V-V ECMO) is limited. The aim of our study is to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on V-V ECMO. Methods: We analyzed prospectively collected observational data of adults from 380 institutions of 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry. We used univariable and multivariable survival modeling to identify risk factors for stroke during ECMO. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks. Results: 595 patients (median age [IQR]: 51 years [42-59]; male: 70.8%) had V-V ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity [adjusted Hazard Ratio (aHR)=2.19, 95% CI=1.05–4.59] and use of vasopressors before ECMO (aHR=2.37, 95% CI =1.08–5.22) were associated with an increased risk of stroke. Relative ΔPaCO2 of negative 26% and relative ΔPaO2 of positive 24% at 48-hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPaCO2 of negative 17% and relative ΔPaO2 of positive 7% in the non-stroke group. Patients with acute stroke had a 79% in-hospital mortality compared with a 45% mortality for stroke-free patients.Conclusion: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on V-V ECMO. Also, the importance of relative decrease in PaCO2 and moderate hyperoxia within 48-hours after ECMO initiation were additional risk factors.
Subject(s)
COVID-19ABSTRACT
Background: COVID-19 has changed the world as we know it, and the United States continues to accumulate the largest number of COVID-related deaths worldwide at the time of publication. There exists a paucity of data regarding the effect of COVID-19 on adult cardiac surgery trends and outcomes on a national level.Methods: The STS Adult Cardiac Surgery Database was queried and analyzed from January 1, 2018 to June 30, 2020. The Johns Hopkins COVID-19 database was queried from February 1, 2020 to January 1, 2021. Surgical and COVID-19 volumes, trends, and outcomes were analyzed on a national and regional level. Observed-to-expected ratios were used to analyze mortality for all risk-adjustable cardiac procedures.Findings: A total of 717,103 adult cardiac surgery patients and more than 20 million COVID-19 patients were included for analysis. The South Atlantic (21.1%) and Great Lakes (17.4%) regions contributed the most patients during the study period. Nationally, there was a 52.7% reduction in overall adult cardiac surgery volume, and a 65.5% reduction in elective cases. The Mid-Atlantic region was most affected by the first COVID-19 surge, with a 69.7% reduction in overall case volume and 80.0% reduction in elective cases. In the Mid-Atlantic and New England regions, the observed-to-expected mortality for isolated coronary bypass increased as much as 1.48 times (148% increase) pre-COVID rates. After the first COVID-19 surge, nationwide cardiac surgical case volumes increased but did not return to baseline, indicating a COVID-associated deficit of cardiac surgery patients.Interpretation: This study is the largest analysis of COVID-19 related impact on adult cardiac surgery volume, trends, and outcomes. During the COVID-19 pandemic, cardiac surgery volume suffered dramatically, particularly in the Mid-Atlantic and New England regions during the first surge of COVID-19 cases, with a concurrent significant increase in observed-to-expected 30-day mortality. Funding: None.Conflict of Interest: TCN – Consultant, Edwards LifeSciences, Abbott, LivaNova, CryoLife. VHT – Consultant/research, Abbott, Boston Scientific, Edwards LifeSciences, W. L. Gore & Associates, Jenavalve. APN – None. RHH – None. JAD – None. JAC – None. AR – None. HM – None.DMS – None. JPJ – None. VB – Consultant, Abbott.