In it for the long run! Long-Term ECMO as a Bridge to Recovery in Severe COVID-19 ARDS

Introduction: During the pandemic, various guidelines were developed for the utilization of extracorporeal membrane oxygenation (ECMO) for COVID-19 ARDS. However, once patients were cannulated for ECMO, the timeframe for lung recovery and referral for lung transplantation was less clear. To date, there are few reported cases of successful long-term (>28 days) ECMO as a bridge to lung recovery. Method(s): We present three patients who were referred for lung transplantation for severe COVID-19 associated respiratory failure and ultimately achieved successful lung recovery following long-term venovenous ECMO support. Patients presented at different stages of the pandemic, were of different ethnicities, aged 35-54 years old, average BMI of 27.6 and two were male. Prior to cannulation, all patients failed mechanical ventilation, prone positioning, neuromuscular blockade and pulmonary vasodilators. Patients were cannulated within 7 days of intubation, underwent early tracheostomy and participated in ambulatory physical therapy. Complications during ECMO included acute renal failure requiring renal replacement therapy, pneumothorax, right ventricular dysfunction and concomitant bacterial pneumonia with bacteremia. The median duration of ECMO was 104 days (range 84-142 days). Radiographic imaging reported end stage restrictive changes in all patients. Survival to hospital discharge was 100%. All patients had complete renal recovery, resolution of RV dysfunction and functional independence without oxygen. Radiographic changes and pulmonary function continued to improve after decannulation. Conclusion(s): Long-term ECMO is an effective strategy for lung recovery in severe COVID-19 ARDS. Duration of ECMO support and radiographic findings should not be used alone to determine recoverability or need for lung transplantation.

Outcomes of Critically Ill Lung Transplant Recipients with COVID-19

Critically ill patients with COVID-19 are at high risk of morbidity and mortality. This risk may be even higher among lung transplant recipients (LTxRs) as they are immunosuppressed and typically older with multiple co-morbidities. The aim of this study was to characterize the outcomes of critically ill LTxRs with COVID-19. LTxRs with COVID-19 hospitalized in the ICU between 06/01/2020 and 02/28/2021 were included and classified as alive or deceased. Baseline clinical characteristics, laboratory results, and complications were reviewed. Death due to COVID-19 was the primary outcome. Descriptive statistics were used. Twenty-five LTxRs (13 men;8 alive, 17 deceased) were included. Median (IQR) age, interval between LTx and COVID-19 diagnosis, and duration of ICU stay was 66 years (56, 71), 27 months (10, 51), and 19 days (10, 28), respectively. Pre-existing diabetes and chronic kidney disease were common (68%, 68%). Although statistical significance was not reached due to small sample size, survivors trended toward lower levels of CRP, ferritin, and D-Dimer at ICU admission. Fewer survivors had a stroke (0% vs 6%), hemorrhage requiring transfusion (14% vs 18%), new-onset heart failure (14% vs 29%), venous thromboemboli (24% vs 33%), and renal failure requiring dialysis (25% vs 53%). At a median of 8 days after COVID-19 diagnosis, 18 (72%) LTxRs required intubation. The need for mechanical ventilation increased the risk of death 4.327-fold (p=0.054) and lowered the probability of 60-day survival (16.7% vs 71.4%, p=0.035;Figure 1). The median survival of deceased subjects was 23 days (17, 34). Most LTxRs received corticosteroids, convalescent plasma, remdesevir, and reduced immunosuppression. Among LTxRs that survived to hospital discharge, 38% (3) were discharged home, 50% (4) required acute rehabilitation, and 75% (6) were supplemental oxygen dependent. Critically ill LTxRs with COVID-19 have high morbidity and mortality. The need for mechanical ventilation portends a poor prognosis. [ 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.)