ABSTRACT
Objectives: With the occurrence of the COVID-19 pandemic in the year of 2020 the number of patients in need ofintensive care medicine increased dramatically in many countries. Several of them developed an acute respiratory distresssyndrome (ARDS) linked to the COVID-19 infection and many required the use of extracorporeal membrane oxygenation(ECMO). Methods: We are retrospectively reviewing 141 patients who underwent ECMO for severe COVID-19-related ARDS in amulticenter study at 10 European ECMO centers. Result: A total of 141 patients (67.4% male, median age was 55.4 years (interquartile range [IQR]: 44-67.5) were treatedwith ECMO for confirmed (132) or suspected (9) severe COVID-19-related ARDS. Before ECMO, the median SequentialOrgan Failure Assessment (SOFA) score was 9.0 (IQR: 7.0-11.5), median pH was 7.25 (IQR: 7.20-7.30), and medianPaO /FiO ratio was 70 mm Hg (IQR: 60-77). Venovenous ECMO was provided in 130 patients (92%) and venoarterial ECMO in 11 patients (8%) The median duration ofECMO treatment by now was 11 days, IQR: 7-17). At the time of reporting, 71 confirmed COVID-19 patients (53.8%) arealive, of whom 33 (43.4%) are still in the intensive care unit (9 on ECMO, 24 weaned from ECMO and extubated). Overallmortality so far occurred in 62 patients (46.2%). By now advanced age, low arterial pH, and low platelet count before ECMO were independent risk factors for increasedmortality during the intensive care treatment. Conclusion: Despite a substantial overall mortality of over 40%, approximately half of the patients with severe COVID-19-related ARDS, refractory to conventional treatment, may be successfully managed with ECMO therapy.
ABSTRACT
Purpose As Italy faced SARS-CoV-2 outbreak as first country outside China, and our hospital converted most of activities into the ones for COVID-19 patients (pts), we had to manage the need for continuing care of advanced heart failure (HF), heart transplant (HT) and LVAD pts. TM was a possible strategy, but its role in this very sick cohort is unknown. Methods During the lockdown (03-05/2020), we decided to make either a phone (PV) or an in presence (IV) visit, selecting for IV pts listed for HT, with LVAD, recently HT, scheduled for a biopsy within 6 months after HT or a RHC for listing eligibility. In PV, we assessed symptoms, blood pressure, drugs, and programmed a subsequent IV. All pts in IV group were triaged by phone for COVID-19 symptoms or contacts and if scheduled for RHC or biopsy received SARS-CoV-2 swab 48 h before the procedure. Study endpoints were: combined incidence at 6 months of MACE (HF hospitalization, CV death and need for anticipated IV) in HF/VAD group, and MACE, rejection and any cause- hospitalization in HT group. Results Among 448 pts (57±12y, 240 HT, 191 HF, 17 LVAD), 52% were managed by PV and a subsequent IV was scheduled after 3±2 months. Pts managed by PV were healthier: in HF-VAD group they were less frequently listed, had less Afib, LVAD (2/17) (p<0.01 all);post-capillary PH (pC-PH) was similarly distributed;in HT group there were less pts transplanted in the last 5 years (15% vs 52%, p<0.01) and numerically less with 2R rejection in the previous 6 months (8.3% vs 27.1%, p=0.13).The PV group had a lower incidence of the endpoints in both HF/VAD and HT cohorts (92.3±2.3% vs 70.3±4.4%;97.0±1.7%vs82.5±4.1%, p<0.01). Overall, the predictors of the endpoints at multivariate analysis were pC-PH and PV (HR: 5.2 and 0.1, p<0.03 both) and a recent 2R rejection (HR: 3.6, p=0.05) in the HF/VAD and HT group respectively.There were no cases of COVID-19 in IV;5 pts got infected at home in a context of infection prevalence of 6/1000 inhabitants in our region and of 40% of hospital beds dedicated to COVID-19 pts. Conclusion In this retrospective study, by reporting an organization set up in a emergency situation, we show that TM can be safely used to manage stable HF, LVAD and HT patients, whereas pC-PH and a recent rejection may identify those needing IV. These data suggest that the availability of devices for monitoring pulmonary pressures may improve safety of PV in HF pts and that TM could be useful not only in a pandemic outbreak but also subsequently.
ABSTRACT
Purpose Left ventricular assist devices (LVAD) have been developed to support cardiocirculatory function in patients with advanced heart failure, who are refractory to optimal medical treatment. This created the need to identify a professional figure for dedicated management of LVAD patients. Methods In this report, we analyzed all the accesses of all consecutive adult LVAD recipients at our outpatient care unit and the impact of VAD coordinator clinical/technical assessment on patients global management, at the time of COVID-19 pandemic in the period January to August 2020 Results During the study period, 19 LVAD patients had overall 357 contacts with the clinic, for different combinations of: advanced driveline dressing (n=280), log file analysis and technical check-up (n=200), clinical visit (n=102), ramp test (n=17). In the majority of accesses, the patient was seen by the VAD coordinator only, (n=238;67%), mainly for driveline dressing, which was associated with technical check-ups in 89 cases.Overall, alarms were managed by technical check-ups and log file analyses in 14 cases (6 high priority alarms, 3 cases of high watt or low flow, and 5 cases of low-priority alarms). Ramp tests were performed during right heart catheterization, with contextual echocardiography performed by the VAD coordinator: in 11 out of 17 cases the ramp test led to medical therapy or LVAD settings optimization. Conclusion LVAD patients need frequent outpatients dedicated admissions for proper monitoring. The VAD coordinator is a key healthcare professional representing the main interface for LVAD patients, in support of physicians’ throughout the duration of mechanical support, to preserve optimal outcomes.