ABSTRACT
Purpose of Study: The regional NICU is an essential healthcare resource for families of newborns with serious life-threatening illnesses. Mechanical ventilation, cardiovascular therapies, therapeutic hypothermia, and neonatal surgeries are common life-sustaining interventions. Our NICU serves an underprivileged population in a resource poor environment and several ethical questions frequently emerge when facing extremes of innovative therapies. The pandemic and rapidly changing institutional protocols accentuated challenges faced by frontline NICU teams caring for newborns at risk for devastating illnesses and death. Concurrently, evolving paradigms in neonatal ethics required urgent and high quality palliative care in a background of racial and socioeconomic inequities, restrictive visitation policies, and limited healthcare resources. The purpose of this study was to ensure that neonates and their families receive ethically sound care, timely referrals for innovative therapies, and specialized palliative care in the strained and uncertain environment of the COVID-19 pandemic. Methods Used: The key steps consisted of structured and impromptu discussion forums for specialized palliative care and medical ethics, perinatal case conferences and pediatrics grand rounds on virtual platforms, educational webinars for interdisciplinary teams, and improved electronic communication. Online collaboration and innovative combinations of in-person and virtual meetings were utilized for urgently Incorporating clinical updates. Summary of Results: 1. A neonate with severe HIE and postnatally diagnosed congenital diaphragmatic hernia required emergent ECMO center referral. NICU providers utilized a structured bioethics and palliative care framework for providing family support and discussing the prognostication challenges of acute illnesses. 2. Many important bioethical questions emerged while caring for infants with life-threatening chromosomal abnormalities. Ethical tension was addressed by teaching tools, quality of life and pediatrics ethics conversations, mitigation of moral distress, contemporary clinical and surgical experience, community engagement, and family perspectives. 3. Ethical conflicts are central in the decision to resuscitate neonates born between 22 and 23 weeks of gestation. To provide urgent prenatal consultations and attend high risk deliveries, we collaborated across geographically distant healthcare systems, unified management strategies and analyzed outcomes data. 4. NEC in several extremely preterm babies had devastating outcomes and the team respected each family's voice with compassionate, shared decision-making for both curative care surgeries and palliative care. Conclusion(s): The new workflows, telephone and video conferences, and redirection to telehealth based family meetings did not change important outcomes during the pandemic. Advocacy and education for integrating bioethics and palliative care were vital facets of neonatal critical care in a resource poor and ever-changing pandemic environment.
ABSTRACT
Primary graft dysfunction (PGD) is the leading cause of short- and long-term mortality associated with lung transplants. The association between pre-donation donor blood transfusion and intra operative massive blood transfusion with PGD has been reported. However the impact of pre-transplantation recipient blood transfusion on PGD risk has not been studied. This study aimed to assess the association between PGD and pre-transplant recipient blood transfusion. We conducted a retrospective study of 206 patients who underwent lung transplant at a single institution from January 2018 through July 2022. Data on patient characteristics, pre-transplantation laboratory values, transfusion requirements, and intra- and post-operative outcomes were collected. Results were analyzed using chi-square and t-tests and logistic regression analyses. PGD 2/3 occurred in 30.1% of the cohort (n=62). Thirty-three patients received a blood transfusion within 4 weeks, while 21 received a blood transfusion within 1 week before their lung transplant. Pre-transplant transfusion was strongly associated with higher incidence of PGD 2/3 (48.5% vs 6.9%, P <0.001). There was no significant difference in one year survival between pre-transplant transfused group and non-transfused group (77.7% vs 88.0 %, P =0.478).In univariate analysis, pre and intra-transplant predictors of PGD3 included younger age (p <0.01), pre extracorporeal membrane oxygenation (ECMO) use (p <0.001), higher lung allocation score (p <0.001), COVID related acute respiratory distress syndrome (p <0.01), lower hemoglobin (p <0.01), lower platelets (p =0.003), lower albumin (p <0.001), higher total bilirubin (p <0.01), lower PaO2 (p <0.02), blood transfusion within 4 weeks (p <0.001), longer operative time (p <0.001), intra-transplant blood transfusion (p <0.001), intra transplant VA ECMO use (p <0.001). In multivariate analysis, lower albumin was an independent risk factor of PGD3 (OR 0.25, 95%CI: 0.08-0.76, P <0.015). Pre-transplant blood transfusion could be attributed to a higher rate of PGD. We found no significant difference in one post lung transplant one year survival between pre-transplant blood transfused recipient group and non-transfused group. [ABSTRACT 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 abstract 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 abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Lung transplantation is a potentially lifesaving treatment for critically ill patients with COVID-19-associated acute respiratory distress syndrome (ARDS). Many patients require extracorporeal membrane oxygenation (ECMO) as life-saving support when other traditional treatments fail. However, there is limited information regarding the long-term outcomes of VV-ECMO use as a bridge to lung transplantation in patients with ARDS. This was a retrospective review of an institutional lung transplant database. We included consecutive lung transplant recipients between June 2020 and June 2022. Demographic, clinical, laboratory, treatment data, the outcomes of lung transplantation, and survival were collected and analyzed. Kaplan-Meier and Wilcoxon tests were used to evaluate survival rates. Among the 41 lung transplant recipients for COVID-19-associated ARDS, 25 patients (median age 53 years [IQR, 36-55];11 women [44.0%]) had ECMO bridges and 16 patients (median age 54.5 years [IQR, 52.75 to 63];7 women [43.8%]) did not. For lung transplant recipients with ECMO bridges compared to those without, the median lung allocation scores were 88.1 vs. 74.9 (p<0.001). During transplantation, patients with COVID-19-associated ARDS received transfusions with a median of ten units of packed red blood cells vs. two units in those without ECMO bridges;96.0% vs. 93.8% underwent intraoperative venoarterial ECMO, and the median operative time was 9.5 hrs. vs. 7.8 hrs., respectively. Postoperatively, the rates of primary graft dysfunction grade 3, within 72 hrs., were 44% in the ECMO bridge vs. 0% in those without them. The median duration of intensive care unit stays was 20 days vs. 13 days, and the median post-lung transplant hospitalization duration was 35 days vs. 19.5 days, respectively. After follow-up (median follow-up period: 448 days [IQR, 314-664] in patients with ECMO bridges vs. 417 days [IQR, 389.5-506] in patients without them), one-year survival rates were 78.3% in patients with ECMO bridges and 100.0% in patients without (p=0.06). In this single-center case series of 41 consecutive patients who underwent lung transplantation for COVID-19-associated ARDS, patients on an ECMO bridge showed a more severe cohort. However, there was no significant difference in the overall outcomes between the two groups (p=0.06). [ABSTRACT 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 abstract 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 abstract. (Copyright applies to all Abstracts.)
ABSTRACT
In patients with COVID-19-associated acute respiratory distress syndrome (ARDS), decreased pulmonary compliance, increased pulmonary vascular resistance and micro pulmonary thrombosis increase the right heart burden, which can lead to right heart failure. However, the impact of lung transplantation for ARDS on the right heart is unclear. Therefore, we evaluated changes in heart function and structural abnormalities with pre- and postoperative transthoracic echocardiography (TTE). This study was a retrospective review of the institutional lung transplantation database from June 2020 to June 2022. Pre- and postoperative TTE were performed, and postoperative TTE beyond 90 days was recorded. Right ventricular (RV) function and size were evaluated and scored. The Wilcoxon signed-rank test was used to compare pre- and postoperative TTE values. During the period, 42 patients underwent lung transplantation for COVID-19-associated ARDS: 10 were excluded (two single-lung, one lobar, one dual-organ transplant, and six patients with missing postoperative TTE data);and 32 were included in the study. TTE was evaluated at a median of 15 days preoperatively (IQR 9.5-30) and 144.5 days postoperatively (IQR 112-210). Pre- and postoperative TTE showed significant changes in mitral A, lateral E', RV estimated systolic pressure (RVSP), RV function and size (Figure 1 and Table 1). In patients with severe right heart dysfunction due to COVID-19-associated ARDS, RV function and structure normalized within a relatively short period after lung transplantation. [ABSTRACT 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 abstract 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 abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Severe right heart failure (RHF) is a known complication of pulmonary hypertension, which increases mortality before lung transplantation. The safety and feasibility of venovenous (VV)-extracorporeal oxygenation (ECMO) using ProtekDuoTM (CardiacAssist Inc., Pittsburgh, PA) as a bridge to lung transplantation in severe RHF caused have not been well studied. This study aimed to evaluate the safety and feasibility of VV-ECMO using ProtekDuoTM as a bridge to lung transplantation in patients with severe RHF. This study was a prospective review of the institutional lung transplantation database from June 2020 to June 2022. Patients who underwent lung transplantation with VV-ECMO using ProtekDuoTM for COVID-19 associated acute respiratory distress syndrome (ARDS) were prospectively enrolled;and preoperative and postoperative transthoracic echocardiographic (TTE) data were analyzed. RV function and size were evaluated and scored. The Wilcoxon signed-rank test was used to compare pre- and post-operative TTE values. During the study period, 20 patients underwent lung transplantation for COVID-19-associated ARDS with preoperative VV-ECMO using ProtekDuoTM. TTE was assessed at a median of 15 days preoperatively (IQR, 7.75-31) and 155.5 days postoperatively (IQR, 112-210). Pre and post-operative median RVSP was 45.4 mm Hg (IQR, 29.4-49.0) and 30.0 mm Hg (IQR, 28.0-35.0), p=0.02, and the median mitral valve A was 0.70 cm/s (IQR, 0.70-0.80) and 0.55 cm/s (IQR, 0.50-0.70), p=0.03 (Table1). All patients were hemodynamically stable with active rehabilitation and did not require inotropes or inhaled nitric oxide. VV-ECMO with ProtekDuoTM for patients with COVID-19-associated ARDS before lung transplantation can stabilize patients without significant complications and allows active rehabilitation of patients with severe RHF. [ABSTRACT 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 abstract 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 abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Cytomegalovirus (CMV) infection is associated with poor outcomes after solid organ transplantation. The long-term impact of donor and recipient CMV serological status on lung transplant outcomes has been considered a risk factor for mortality, which donor CMV-IgG positive-recipient CMV-IgG negative (D+R-) group is a high risk for CMV infection and mortality. However, the risk factors in this group of patients remain unclear. We evaluated the impact of donor and recipient CMV status on long-term outcomes, as well as the risk factors for CMV infection. This was a prospective review of the institutional lung transplantation database from June 2014 to June 2022. Data on patient characteristics, pre-transplantation laboratory values, postoperative outcomes, and CMV infection were collected. All patients received a prophylactic dose of valganciclovir hydrochloride (900 mg once daily) after lung transplantation. The donor positive-recipient CMV-IgG negative group was defined as the CMV-mismatch group. The results were analyzed using the chi-square test, Mann-Whitney U test, t-test, logistic regression analyses, and receiver operating characteristic curve analysis. During the study period, 257 patients underwent lung transplantation. CMV infection was detected in 69 patients (26.8%):25 of 203 (12.3%) in the non-CMV mismatch group and 29 of 54 (53.7%) in the CMV mismatch group (p<0.001). CMV infection occurred 395 days (IQR;264-452) in the entire cohort. In multivariate logistic analysis, COVID-19-associated acute respiratory distress syndrome etiology, lower albumin level, and CMV mismatch were independent factors for CMV infection (COVID-19-related ARDS, OR=3.03, 95% CI=1.20-7.64, p=0.02;albumin [g/dl], OR=0.34, 95% CI=0.16-0.70, p<0.01;CMV mismatch, OR=6.66, 95% CI=2.79-15.9, p<0.001). Receiver operating characteristic curve analysis showed that an albumin of 4.0 g/dl was the cut-off value (area under the curve=0.64) for the risk of CMV infection. In the CMV mismatch group, hemodialysis use after discharge was associated with CMV infection (OR=9.10, 95% CI=1.02-82.4, p=0.04). In patients with CMV mismatch, hemodialysis use was an independent predictor of CMV infection. Further studies are needed to determine the risks and benefits of extending CMV prophylaxis or aggressive CMV treatment, particularly in high-risk groups. [ABSTRACT 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 abstract 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 abstract. (Copyright applies to all Abstracts.)
ABSTRACT
Background: Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is increasingly being utilized to manage critical COVID-19 associated ARDS (CCAA) in patients who fail medical optimization and mechanical ventilatory support. The aim of this study was to determine the probability of weaning patients from ECMO over time and whether a subset of patients should be considered for lung transplantation. Additionally, we investigated when lung transplant should be considered after VV ECMO support. Methods: 49 patients with CCAA who required ECMO between January 2020 and September 2021 were investigated. Baseline patient demographics, clinical, laboratory, and follow-up data were compared. The change in probability of ECMO weaning based on duration of ECMO support was studied using a univariate analysis. Additionally, patients who received lung transplantation following VV ECMO for COVID-19 during this same period were studied to compare outcomes to those of patients with only VV ECMO support. Cox proportion hazard analysis was performed to determine predictors of survival in patients who required greater than 28 days of ECMO support. Yuden index was used to determine change in probability of survival with time on ECMO. Results: Of 49 patients, 17 (35%) received lung transplants and 32 (65%) remained on ECMO for >28 days. The probability of weaning patients from ECMO was highest within the first 10 days (60%);beyond 40 days, it was 5.1% (Fig. A). The probability of successfully weaning patients from ECMO significantly decreased over time and ECMO support greater than 28 days (Yuden index, Hazard ratio: 1.09, 95% CI;1.00-1.03) was associated with a significantly increased risk of mortality. Additionally, both survival to hospital discharge (p<0.001, Fig. B) and post-discharge survival (p<0.001, Fig. C) were significantly greater in those who were weaned from ECMO prior to 28 days than those who were weaned after 28 days. In those who could not be weaned from ECMO, lung transplantation (HR:0.47, p<0.01, 95% CI 0.17-0.94), ECMO duration (HR:1.09, p=0.01, 95% CI 1.00-1.03) and higher BUN levels (HR:1.02, p<0.01, 95% CI 1.01- 1.46) prior to ECMO initiation were independent predictors of survival. ECMO support of greater than 8 days was associated with a statistically significant increase in mortality compared to those who received fewer than 8 days of support (Yuden index, HR 1.96, CI 1.06-5.51). Furthermore, the projected survival of patients on ECMO support for greater than 8 days was substantially worse than those requiring fewer than 8 days of support (Fig. C and D). Conclusion: This study suggests that survival and accompanying lung recovery is more probable in patients who require a short duration of ECMO support whereas those who require longer durations, particularly exceeding 28 days, is associated with a lower rate of survival. (Figure Presented).
ABSTRACT
Purpose Traditionally, severe acute respiratory distress syndrome (ARDS) patients on veno-venous extracorporeal membrane oxygenation (VV ECMO) receive significant sedation and neuromuscular blockade (NMB) to facilitate lung protective mechanical ventilation. However, we previously showed the feasibility of managing these patients without mechanical ventilation, sedation, or NMB. Reduced levels of sedation allows patients to begin physical and occupational therapy (PT/OT) early on. Here, we investigate the impact of early PT/OT initiation on day of discharge (DOD) functional activity for severe ARDS patients managed on VV ECMO. Methods This is a retrospective review of all patients who underwent VV ECMO as management for severe ARDS at a single academic center from February 2018 to June 2021. Data collected included patients’ demographics, co-morbidities, etiology of ARDS, days of ECMO support before PT/OT initiation, and ambulation distance and PT/OT Activity Measure for Post-Acute Care (AMPAC) Six-Clicks score on DOD. Results 67 patients were included in this study. Those with >7 days on VV ECMO had decreased ambulation and AMPAC scores compared to those with < 7 days (N=41, 70.5 ± 113.3ft vs N=26, 162.1 ± 154.1ft, p<0.01, 12.3 ± 5.9 vs 16.4 ± 6.8, p=0.01, respectively). PT/OT initiation within 7 days after starting VV ECMO significantly improved ambulation and AMPAC scores compared to those with >7 days of VV ECMO prior to any PT/OT (N=30, 163.5 ± 160.5ft vs N=37, 59.5 ± 93.5ft, p<0.001, 16.6 ± 7.1 vs 11.8 ± 5.2, p<0.01, respectively). In patients with >7 days on VV ECMO, those who began PT/OT within 10 days of starting VV-ECMO had improved ambulation and AMPAC scores compared to those with >10 days of VV ECMO prior to PT/OT (N=9, 151.8 ± 164.8ft vs N=32, 44.2 ± 77.8ft, p<0.01, 16.5 ± 7.7 vs 11.0 ± 54.5, p<0.01, respectively). Conclusion Early PT/OT initiation in severe ARDS patients managed on VV ECMO is associated with improved patient functional activity on DOD. This may provide benefits such as enhanced recovery, increased ability to complete activities of daily living, and improved cognitive health. Our study further supports the use of VV ECMO in treatment of severe ARDS without mechanical ventilation, sedation or NMB and specifically demonstrates PT/OT should be started early following initiation of VV ECMO to improve patients’ functional outcomes.
ABSTRACT
Introduction: Dual-lumen cannula is used for extracorporeal membrane perfusion (ECMO) to support patients with ARDS due to COVID-19 as a bridge to lung recovery. It tends to be a longer support and there are several factors that can degrade the physical structure of the ECMO cannula and put the cannula at risk for breakage. Case Report: A 63-year-old woman was admitted to the hospital with COVID-19 pneumonia. Two days later, she was intubated and VV-ECMO was initiated due to treatment-resistant acute respiratory failure;a 28Fr CrescentTM dual-lumen cannula (Medtronic, MN) was inserted through the left subclavian vein and connected to a centrifugal oxygen pump with a centrifugal oxygenator. Within six weeks after onset, the patient was unable to be weaned from the ventilator and was transferred to our center with ECMO connected for consideration of lung transplantation. Two days after transfer, the patient developed acute aphasia, altered mental status, disturbed consciousness, and left arm seizures. A suction sound was heard from the left subclavian cannula insertion site and the ECMO bubble detector alarmed, but local inspection, chest X-rays, and CT scans of the brain and chest showed no obvious abnormalities. The patient was reintubated for encephalopathy and subsequently underwent a tracheostomy. The patient regained normal neurological function over the next 7 days. However, the air bubble sensor alarmed and suction sound was heard at the cannulation site again, and air bubbles were seen in the oxygenator. Due to concerns about air entrapment and cannula failure, we changed to a dual-canal VV-ECMO configuration using a right internal cervical and a left femoral cannula. The removed cannula had a 2 cm fracture distal to the skin insertion site. After resumption of ECMO, no new neurological episodes occurred. While awaiting lung transplantation, the patient died due to sepsis and multiple organ failure. An autopsy revealed a possible cause of cerebrovascular disease patent foramen ovale and air embolism to the brain. If a patient has been on ECMO for a long time and the bubble sensor warns of air detection, cannula breakage and impending air embolism should be suspected clinically, even if the defect is not found on examination and is not evident on imaging. If the COVID-19 epidemic continues, increased transport events may increase ECMO cannula breakage.
ABSTRACT
: Lung transplantation is a potentially lifesaving treatment for severe COVID-19 acute respiratory distress syndrome (ARDS), when optimized medical treatment fails to accomplish lung recovery. However, since the long-term outcomes remain unknown, concerns related to the use of lung transplantation in critically ill COVID-19 patients persist. In the current study, we evaluated consecutive patients that underwent lung transplantation for severe COVID-19 ARDS at our center and compared their post-transplant outcomes with those undergoing transplantation for non-COVID-19 pathology during the concurrent study period. All consecutive patients undergoing lung transplantation between January 2020 to May 2021 were included. The study included two cohorts of patients that underwent transplantation for non-COVID-19 disease (nC19) or refractory COVID-19 ARDS (C19). For additional analysis, we included consecutive patients with severe COVID-19 that required veno-venous extracorporeal membrane oxygenation (ECMO). We found that post-procedure complications and length of stay were significantly greater compared to transplants performed for non-COVID-19 lung diseases during the concurrent study period. Following transplant the COVID-19 cohort demonstrated a more rapid improvement in Karnofsky performance status. At one year, all recipients in COVID-19 cohort were alive with post-transplant survival no different than institutional non-COVID-19 recipients. Furthermore, when compared to propensity-matched recipients from SRTR, post-transplant survival of institutional COVID-19 ARDS patients was non-inferior. There was progressive reduction in the probability of separation from extracorporeal membrane oxygenation (ECMO) with time and ECMO support greater than 30 days was associated with a significantly greater risk of death in patients with COVID-19 ARDS. In those who remained unweanable from ECMO after 30 days, lung transplant was an independent predictor of survival. We conclude that lung transplantation in selected patients with severe COVID-19 ARDS who remain unweanable from extracorporeal life support can result in post-transplant outcomes comparable to recipients with chronic end-stage lung diseases and non-COVID-19 ARDS. [ 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.)
ABSTRACT
Rationale: Coronavirus disease 2019 (COVID-19) can cause severe respiratory failure that worsens despite maximal medical management. When to initiate extracorporeal membrane oxygenation (ECMO) and how to manage these patients on ECMO is not clear. Here, we present our experience with venovenous ECMO to support patients with COVID-19 and compare it to historic patients supported with VV-ECMO for other causes of respiratory failure. Methods: Patients admitted to our tertiary academic medical center in 2019 and 2020 who received VV ECMO support were included in this retrospective chart review. We examined patients with and without COVID-19 infection. We placed COVID-19 patients on ECMO who failed supportive care with mechanical ventilation using a high PEEP low tidal volume strategy, prone positioning, and neuromuscular blockade. Data analysis were done in Excel and Prism. Non-parametric data were compared with unpaired, two-tailed Mann-Whitney tests. Results: ECMO was provided to 26 COVID-19 patients and 38 patients without COVID-19. Median (interquartile range) age of COVID-19 patients was 49.5 (40.5-56.25), compared with non-COVID-19 patients: 53.5 (30.5-60.25), p=0.28. COVID-19 patients had a significantly higher BMI: 32 (30.1-35.9) vs. 26.4 (23.6-29.4), p<0.001. There were 27% female COVID-19 patients compared with 37% female non-COVID patients (p=0.43). COVID-19 patients had similar PaO2:FiO2 ratios as non-COVID patients on day of cannulation: 74 (69-112) vs 78 (60-205), p=0.65. COVID-19 patients had longer ventilator duration pre-cannulation (not including time spent intubated at outside hospitals prior to transfer to our center)-1.9 (1.4-7.0) days vs 0.7 (-.2-1.0) days, p<0.001. COVID patients spent more days on ECMO compared with non-COVID patients: 20.7 (7.3-36.5) vs. 11.5 (3.8-26.8), p=0.14. Twelve (46%) of the COVID-19 ECMO patients died, compared with 9 (25%) of the non-COVID ECMO patients, p=0.10. Conclusions: In patients with severe SARS-CoV-2 pneumonia induced ARDS who fail maximal supportive therapy with mechanical ventilation, outcomes are similar or worse than patients historically receiving VV ECMO support for respiratory failure. These findings highlight the need to determine the optimal timing of ECMO initiation and management in patients with severe SARS-CoV-2 pneumonia.
ABSTRACT
Introduction Lung transplantation can potentially be a life-saving treatment for patients with non-resolving COVID-19 acute respiratory distress syndrome. Concerns limiting transplant include recurrence of SARS-CoV-2 infection in the allograft, technical challenges imposed by viral-mediated injury to the native lung. Here, we report the first successful lung transplantation in a patient with non-resolving COVID-19 associated acute respiratory distress syndrome in the United States. Case Report The recipient was a 28-year old female with past medical history of neuromyelitis optica treated with mycophenolate and rituximab who developed COVID pneumonia leading acute respiratory distress syndrome. The patient was intubated for 8 days with prone prior to initiation of VV ECMO. Her ECMO course was complicated by right sided pneumothorax requiring multiple pleural tubes and the development of Serratia marcescens pneumonia with left lower lung necrosis, and a liver capsular bleed necessitating emergent exploratory laparotomy. (Figure1a, b) She received antibiotics, remdesivir, hydroxychloroquine, tocilizumab, and convalescent plasma. However there was no signs of recovery and she was listed for lung transplantation after ECMO support for 32 days . Implantation was supported with central VA ECMO, and there was severe dense vascular adhesions bilaterally with severe distortion of hilar. (Figure1c) Explanted Lungs damaged by COVID-19 were free of virus but pathology showed extensive evidence of acute interstitial inflammation with fibrosis which consistence with end-stage pulmonary fibrosis. (Figure1d, e) The patient was decannulated from VV ECMO on POD 17, and was discharged on POD 27. (Figure1f) Four months after transplantation, she is at home with oxygen saturations above 98% on room air. Summary Our experience suggest that lung transplant is the only option for survival for some patients with severe COVID-19 develop fibrotic lung.
ABSTRACT
Purpose The use of extracorporeal membrane oxygenation (ECMO) support is increasingly used in the management of COVID-19-related acute respiratory distress syndrome (ARDS). The effect of ECMO for patients with severe ARDS in the context of COVID-19 is unclear. This study is to summarize the clinical features, and outcomes of patients with severe ARDS due to COVID-19 treated with ECMO. We analyzed the incidence of morbidity including ischemic/hemorrhagic stroke, gastrointestinal bleeding, pump malfunction, oxygenator dysfunction, infection during VV ECMO. We also compared COVID ECMO patients to non COVID-19 ECMO patients. Methods This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through July 2020. 138 patients (mean age, 47.0 ± 14.4 y) with respiratory failure who underwent VV ECMO implantation were included in this study. Patients were stratified into two cohorts: those with COVID-19 or non COVID-19. Results Patients with COVID-19 had higher body mass index (33.4 ± 5.9 vs 28.8 ± 8.9, p<0.01), also had lower albumin level (2.7 ± 0.5 vs 3.1 ± 0.7, p<0.01). Patients with COVID-19 demonstrated not significantly lower survival rates (p=0.16). There was also no significant difference between 2 groups in incidence of acute kidney injury (p=0.17), dialysis (p=0.82), tracheostomy, (p=0.22), neurological dysfunction (p=0.19), gastrointestinal bleeding (p=0.42), oxygenator dysfunction (p=0.37), and sepsis (p=0.75). However, ECMO support days were significantly longer in COVID ECMO patients. (29.0 ± 27.5 vs 15.9 ± 19.6 days, p<0.01). Conclusion These findings suggest that COVID related ARDS was not associated with a higher postoperative mortality rate than non COVID related ARDS patients, even though support days of ECMO was longer in those groups. ECMO should be considered for patients developing ARDS despite optimised care.