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Heart transplant recipients are at a very high risk of adverse outcomes after SARS-CoV-2 infection. There is no clear guidance on how to manage immunosuppression (IS) on heart transplant patients with COVID-19;in most studies IS was decreased or held. At our center, however, we deliberately maintained IS with the premise that this would result in a reduced inflammatory response to COVID-19. In this study we present our single center experience of heart transplant recipients infected with COVID-19 in whom IS was maintained. Retrospective analysis from June 2020 to February 2022 of heart transplant recipients followed at our center that tested positive for COVID-19. Patient demographics, comorbidities, baseline IS, hospitalization, ICU need, O2 requirement, mechanical support requirement and mortality were recorded. During the study period, 581 transplants were followed at our center, we documented 65 cases of COVID-19 (Table 1). The average age was 58 years, 75% male, 51% Caucasian. 50% had DM, 69% HTN and 48% CKD. Median time since OHT was 4.6 years. 71% of the patients were on dual IS. All patients remained on their baseline immunosuppression. Of the 65 patients, 37% required hospitalization, 9% ICU-level of care. Median LOS was 5.5 days. Mortality was 8%, there were no events of rejection or allograph dysfunction. Our data suggest that maintenance of therapeutical levels of IS in patients with COVID-19 is safe in heart transplant recipients. Our outcomes were comparable to those of the existing literature. Larger studies are needed to further validate our results. [ FROM AUTHOR] Copyright of Journal of Heart & Lung Transplantation is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)
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INTRODUCTION: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used successfully to treat COVID-19 patients in severe respiratory failure. The objective of our multi-center study is to evaluate mortality, time of ECMO initiation, and demographics in COVID-19 patients treated with VV-ECMO. METHOD(S): Electronic medical records from March 2020 to October 2021 were studied in 49 sites across the United States. Patients treated with ECMO who tested positive for COVID-19 were included in this retrospective data analysis (N=363, age interquartile range: 37-55 years). Odds of inhospital mortality were compared using logistic regression models. At thresholds 1-7 days, patients classified as 'early ECMO' were matched to 'delayed ECMO' patients using coarsened exact matching, resulting in 7 independent analyses for early/delayed ECMO cannulation relative to the number of days of pre-ECMO mechanical ventilation (MV). RESULT(S): There were no significant differences in mortality in patients who received early or delayed ECMO. There were also no significant differences in mortality between races, body mass index (BMI), smoking status, hypertension, chronic kidney disease, coronary artery disease, steroid use, or diabetes pre-cannulation. Lastly, pre-cannulation factors associated with mortality in COVID-19 patients treated with ECMO include the use of vasopressors, which was associated with an 87% increase in mortality (p=0.017, confidence interval [CI] 1.12, 3.15);proning, which was associated with a 85% increase in mortality (p=0.015, CI 1.13, 3.06);and the use of baricitinib, which was associated with a four-fold increase in mortality (p=0.041, CI 1.11, 17.6). CONCLUSION(S): We found no evidence that particular demographic characteristics (including race, BMI, or smoking status) contribute to mortality, nor did we find evidence that the length of time on MV prior to ECMO influences mortality. The analysis of large datasets in the ECMO population may better inform clinical decision making.
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INTRODUCTION: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is typically used to support severe ARDS after the failure of invasive mechanical ventilation (IMV). IMV may cause harm in patients with preexisting barotrauma, shock, or immune compromise. METHOD(S): Single center case-control study of VV-ECMO before IMV (awake ECMO;n=24) compared to conventional ECMO (n=76) after IMV in COVID-19 patients. Groups were compared at baseline before cannulation (awake ECMO) or intubation (conventional ECMO). Propensity matching was performed based on body mass index and injury severity (Simplified Acute Physiology Score II [SAPS II], PaO2:FiO2 ratio). The primary outcome was survival to discharge. Secondary measures of duration of IMV and adverse events were examined. Multivariable adjustments were performed. RESULT(S): Awake ECMO compared to conventional ECMO patients at baseline were more tachypneic (mean +/- standard deviation: 36.3 +/- 9.6 vs 27.4 +/- 7.3;p< 0.0001) with lower SpO2 (median [interquartile range]: 87% [81-92.5] vs 93% [87-96];p=0.01) but similar SAPS II. Fifteen (68%) of awake ECMO patients eventually required IMV. Survival to discharge in awake ECMO trended towards improvement compared to conventional ECMO (70.8% vs. 52.6%;p=0.12). After propensity matching, awake ECMO was associated with increased survival (adjusted odds ratio 6.84 [95% confidence interval 1.08 - 43.38]). Awake ECMO was associated with less duration of IMV before and after propensity matching. Adverse events were similar between groups. CONCLUSION(S): Awake ECMO before IMV is associated with acceptable survival, similar adverse events, and shorter duration of IMV compared to conventional ECMO. This strategy may be preferable in carefully selected patients.
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SESSION TITLE: Critical Care Management of COVID-19 SESSION TYPE: Original Investigations PRESENTED ON: 10/17/2022 01:30 pm - 02:30 pm PURPOSE: Extracorporeal membrane oxygenation (ECMO), typically veno-venous, is used to treat COVID19 patients with severe acute respiratory distress syndrome (ARDS) and is associated with decreased mortality in some reports. This study sought to determine the effect of ECMO versus conventional invasive mechanical ventilation (IMV) on hospital mortality for ARDS due to COVID19, and to compare functional status at discharge. METHODS: This was a retrospective, multicenter cohort study of adult patients admitted for COVID19 within a large US hospital network between March 1, 2020 and October 31, 2021. Patients were included if they required IMV with a fraction of inspired oxygen (FiO2) of at least 80% or VV ECMO. Patients were excluded if they were not independent, had a history of severe neurologic impairment, chronic obstructive pulmonary disease, chronic systolic heart failure, end stage renal disease, cirrhosis, metastatic malignancy, or a length of stay <24 hours. ECMO criteria and management were at the discretion of the treating center. Conventional IMV patients were assigned a randomized pseudo-baseline, and coarsened exact matching was used to match ECMO to conventional IMV patients based on age, sex, body mass index, pre-baseline severity of hypoxemia, prone positioning, receipt of corticosteroids, Tocilizumab, Baricitinib, acute renal replacement therapy, and vasopressors. Differences in hospital mortality and discharge destination were assessed through weighted logistic regression and weighted multinomial logit regression, respectively. RESULTS: We identified 207,965 patients across 168 hospitals for review, and 10,571 patients met study criteria. After matching, 275 ECMO patients and 5,808 conventional IMV patients were available for comparison. ECMO was associated with a significant mortality reduction, 36% versus 61% (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.34-0.57). Compared to conventional IMV survivors, ECMO survivors were significantly more likely to be discharged to acute rehabilitation than long term acute care (relative risk ratio (RRR) 2.23, 95% CI 1.16-4.32). ECMO survivors were also significantly more likely to be discharged to another acute care hospital for further management (RRR 3.21, 95% CI 1.75-5.92). CONCLUSIONS: This study demonstrates that ECMO support is significantly associated with reduced mortality in patients with severe ARDS due to COVID19 compared to conventional invasive mechanical ventilation. Further studies are needed to aid in prognostication, patient selection, and timing of intervention to maximize the benefit of this limited resource. CLINICAL IMPLICATIONS: These findings illustrate the importance of timely referral to an ECMO center for severely ill COVID19 patients, and may influence ECMO-capable centers to expand the use of ECMO in appropriate patients for this indication. DISCLOSURES: No relevant relationships by Elliott Cohen No relevant relationships by Katherine Cyr No relevant relationships by Jeffrey DellaVolpe No relevant relationships by Jamie Jarzembowski No relevant relationships by Chandra Kunavarapu no disclosure on file for Thomas Mcrae;Employee relationship with HCA Healthcare Please note: 6/1/2017 to current Added 04/04/2022 by Daniel Schlauch, value=Salary No relevant relationships by Owen Stell No relevant relationships by sage whitmore