Prolonged V.v.-Ecmo for Covid-19 Ards with Lung Recovery

There is limited data regarding prolonged use of veno-venous extracorporeal membrane oxygenation (V.V.-ECMO) for novel coronavirus disease 2019 (COVID-19) with the expectations of lung recovery or when to transition goals and consider lung transplant. We present a patient with lung recovery after an eight-month ECMO course for COVID-19. In January 2022 a 33-year-old obese (BMI 43), unvaccinated, Hispanic man presented to the emergency department positive for COVID-19 with profound hypoxia requiring intubation. After failing maximum medical therapy, he was cannulated on V.V.-ECMO with a right internal jugular 31Fr single-access, dual-stage right atrium-to-pulmonary artery cannula. Sedation was weaned and he was extubated to ECMO support. Mobilization was initiated immediately with the use of a vertical mobilization bed and progressed to ambulating on ECMO. He demonstrated persistent bilateral airspace disease with complete opacification of both lung fields for several months. With ongoing ECMO support his lung function improved. He was decannulated following eight months of support to nasal cannula and discharged home. He continues to improve at home and is able to engage in all activities of daily living. We demonstrate lung recovery following COVID 19 infection with severe ARDS after prolonged ECMO support. Liberating the patient from the ventilator, weaning sedation, physical therapy and patience resulted in pulmonary recovery. Prolonged ECMO support was required to achieve lung recovery in this patient. [ 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.)

Comparison of cannulation approaches for venovenous extracorporeal membrane oxygenation during covid-19

Purpose: Venovenous extracorporeal membrane oxygenation (VV-ECMO) is performed through various cannulation approaches but an optimal strategy remains uncertain. Methods: A retrospective, multi-center study was conducted. Adult patients (≥18 years old) placed on VV-ECMO for severe respiratory failure due to COVID-19 between March 1, 2020, to April 30, 2021, across the United States were included. Patients were divided into the following 3 groups based on initial cannulation: 1) femoral vein-femoral vein or femoral vein-internal jugular vein (Dual-Site, DS), 2) single, dual-lumen cannula in internal jugular vein with tip positioned in the pulmonary artery (PA) and 3) single, dual-lumen cannula in internal jugular vein with tip positioned in the inferior vena cava (IVC). The primary outcome was in-hospital mortality after VV-ECMO placement assessed by a time-toevent analysis. Results: Overall, 435 patients from 17 centers comprised the study cohort. DS cannulation was performed in 247 (age: 47±11, 30% female) cases, 99 (age 50±12, 26% female) received PA, and 89 patients got IVC (age 45±12, 33% female). At 90 days, in-hospital mortality across cannulation groups was 60% (DS), 41% (PA) and 61% (IVC), p=0.06 (Figure 1). After adjustment for clinical covariates, the likelihood of in-hospital mortality in comparison to DS, was lower with PA (aHR: 0.60, 95%CI 0.40-0.91, p=0.02) and similar with IVC (aHR: 0.99, 95%CI 0.68-1.43, p=0.95). Conclusion: Catheter directed flow into the PA with a single dual-lumen cannula is associated with reduced mortality during VV ECMO for COVID-19.

Outcomes between COVID versus nonCOVID patients receiving venovenous extracorporeal membrane oxygen

INTRODUCTION: Similar to use during the H1N1 pandemic as a means of improved survival in patients with severe acute respiratory distress syndrome (ARDS), there may be a role for extracorporeal membrane oxygenation (ECMO) in patients with severe ARDS secondary to the novel coronavirus (SARS-CoV2 causing COVID). Limited data, however, exists for the use of ECMO in this population. The purpose of this study was to evaluate outcomes between COVID and non- COVID patients receiving venovenous (VV) ECMO. METHODS: This was a retrospective review of 15 COVID and 15 non-COVID patients receiving VV ECMO at Rush University Medical Center. Patients were excluded if they were receiving ECMO at the time of data analysis. The primary outcome was days requiring mechanical ventilation (MV) and ECMO. Secondary outcomes included: discharge disposition, hospital length of stay (LOS) and survival. Data collected included: demographics, co-morbidities, ECMO characteristics, MV and ECMO days, hospital LOS, discharge disposition, and survival. RESULTS: In our cohort, the median age was 45.0 [36.0-51.0] versus 47.0 [36.0-52.0] in the COVID versus non-COVID groups, respectively. Similarly, BMI and comorbidities were not different between groups. A majority of patients in the COVID group were Hispanic (46.7%) versus the non-COVID group (33.3%). Inhaled epoprostenol was delivered prior to ECMO in 73.3% of COVID patients versus 20.0% of non-COVID patients. A 31 French Protek was placed in all COVID ECMO patients versus 46.7% of non-COVID ECMO patients. Days receiving MV were 12.0 [6.0-24.0] and 18.0 [12.0-35.0] and receiving ECMO were 30.0 [23.0-50.0] versus 27.0 days [19.0-56.0] in the COVID and non-COVID groups, respectively. Hospital LOS was 37.0 [29.5-52.5] in the COVID group versus 46.0 [29.0-60.0] days in the non-COVID group. Of note, two patients in the COVID group were hospitalized at the time of data analysis. Survival was 93.3% in both ECMO groups and a majority of patients were discharged to a rehabilitation facility (53.3%). CONCLUSIONS: These data suggest that ECMO may be a useful means of supporting patients with refractory hypoxic respiratory failure secondary to COVID. Future studies are needed to thoroughly evaluate the role of ECMO in this patient population.

1,2,3: Use of Ang II in a HM3

Introduction Vasodilatory shock is characterized by peripheral vasodilation, hypotension and preserved cardiac output. Management involves identifying and treating the underlying cause and reestablishing adequate blood pressure. Contemporary vasopressors include catecholamines and vasopressin, and their use is limited by adverse effects. Adjunctive use of Angiotensin II (Ang II) has been shown to increase mean arterial pressure (MAP) in patients with vasodilatory shock. We describe the first successful use of Ang II in a patient with a HM3 left ventricular assist device (VAD). Case Report 58-year-old gentleman with long-standing NICM, LV EF 20-25%, atrial fibrillation (AF), CKD stage III, recent COVID-19, presented with an ST elevation myocardial infarction and progressed to refractory cardiogenic shock. He was supported with inotropes and an intra-aortic balloon pump and implanted with a HM3. VAD course was complicated by right ventricular dysfunction, respiratory failure, and renal failure, necessitating initiation of continuous dialysis. Patient developed sepsis due to clostridium dificile colitis and pneumonia that progressed to refractory vasodilatory shock on post-op day 20. He was supported on HM3 at 5600 rpm, inotropes and escalating doses of pressors. He developed AF with rapid ventricular response, limiting further uptitration, thus, Ang II was initiated. Initial dose was 20 ng/kg/min, with a robust response in MAPs from 60s to 80s mmHg in 2 minutes. Within 24 hours he was weaned off of Ang II and within 72 hours, he was weaned off of all pressors (Table). He was subsequently transitioned to HD and weaned off of inotropic and ventilatory support. Summary Treatment options for patients with catecholamine-resistant vasodilatory shock are limited. In patients with refractory vasodilatory shock supported with durable LVAD therapies, information on the use of Ang II is limited. In our patient with multi-system organ failure and impending death, we were able to utilize Ang II to provide hemodynamic stability and rescue him from septic shock.

Management of Post Infarction Ventricular Septal Rupture in Contemporary Era

Introduction: During the COVID-19 pandemic, there has been an increase in mortality and complications following STEMI. The rarity of ventricular septal rupture (VSR) in the age of primary percutaneous coronary intervention has resulted in a lack of expertise in its management. Our strategy has been to stabilize patients with venoarterial extracorporeal membrane oxygenation (VA ECMO) then evaluate for surgical repair with revascularization as well as advanced options, such as heart transplantation. Here we present two cases. Case 1: A 65-year-old man with a history of hypertension presented to the hospital with an inferior STEMI and cardiogenic shock. He was found to have acute occlusion of the right coronary artery (RCA) through which a wire was not able to be passed. He also had severe disease in the left anterior descending artery (LAD) and left circumflex artery (LCx). An intra-aortic balloon pump (IABP) was placed. On hospital day 6, hemodynamics worsened and he was found to have a large VSR of the basal inferoseptum and biventricular dysfunction with a left ventricular ejection fraction (LVEF) of 10-15%. He was placed emergently on VA ECMO. Ten days later, he underwent repair of VSR and coronary artery bypass grafting (CABG) with a left internal mammary artery (LIMA) to LAD, and saphenous vein graft to an obtuse marginal. He underwent ECMO decannulation on post operative day 6. He was discharged home on post operative day 23 on medical therapy with an LVEF of 35%. He remains on medical therapy at 6 months. Case 2: A 43-year-old man with a history of hypertension and diabetes suffered an inferoposterior STEMI. Coronary angiography showed acute occlusion of the RCA. He underwent thrombectomy and placement of two bare metal stents with no reflow, and placement of an IABP. He also had chronic occlusion of the LCx and 80% stenosis in the proximal LAD. A post procedure echocardiogram showed LVEF of 35-40%, severe right ventricular dysfunction, and VSR in the mid inferoseptum. He had worsening cardiogenic shock and underwent VA ECMO placement. On hospital day 9, he underwent VSR repair and single vessel CABG with LIMA to LAD. Due to inability to wean off bypass, he required placement of dual-pump biventricular support with Centrimag pumps after which he had persistent ventricular tachycardia. He was listed status 1A and underwent successful heart transplantation on hospital day 20. He is doing well at follow up. We presented two cases of ventricular septal rupture complicating myocardial infarction, both with successful outcomes. During the COVID-19 pandemic, clinicians will need to maintain a high index of suspicion of mechanical complications of late presenting STEMI.