Veno-Arterial Extracorporeal Membrane Oxygenation for Circulatory Failure in COVID-19 Patients: Insights from the ECMOSARS Registry.

OBJECTIVES: The clinical profile and outcomes of patients with Covid-19 who require veno-arterial or veno-venous-arterial extracorporeal membrane oxygenation (VA-ECMO - VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favorable and unfavorable outcomes. METHODS: ECMOSARS is a multicenter, prospective, nationwide French registry enrolling patients who require VV/VA-ECMO in the context of Covid-19 infection (652 patients at 41 centers). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock. RESULTS: Median age was 49. 14% of patients had a prior diagnosis of heart failure. The most common etiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%), and acute coronary syndrome (4%). E-CPR (Extracorporeal Cardiopulmonary Resuscitation) occurred in 38%. In-hospital survival was 28% in the whole cohort, and 43% when E-CPR patients were excluded. ECMO cannulation was associated with significant improvements in pH and FiO2 on day one, but non-survivors showed significantly more severe acidosis and higher FiO2 than survivors at this point (p = 0.030 and p = 0.006). Other factors associated with death were greater age (p = 0.02), higher BMI (p = 0.03), E-CPR (p = 0.001), non-myocarditis etiology (p = 0.02), higher serum lactates (p = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (p = 0.003), hemorrhagic complications (p = 0.001), greater transfusion requirements (p = 0.001), and more severe SAVE and SAFE scores (p = 0.01 and p = 0.03). CONCLUSIONS: We report the largest focused analysis of VA- and VAV-ECMO recipients in Covid-19. Although relatively rare, the need for temporary mechanical circulatory support in these patients is associated with poor prognosis. However, VA-ECMO remains a viable solution to rescue carefully selected patients. We identified factors associated with poor prognosis and suggest that E-CPR is not a reasonable indication for VA-ECMO in this population.

A Successful Case of Cardiac Arrest due to Acute Myocarditis with COVID-19: 120 Minutes on Manual Cardiopulmonary Resuscitation then Veno-Arterial Extracorporeal Membrane Oxygenation.

Acute myocarditis is one of the common complications of coronavirus disease 2019 (COVID-19) with a relatively high case fatality. Here reported is a fulminant case of a 42-year-old previously healthy woman with cardiogenic shock and refractory cardiac arrest due to COVID-19-induced myocarditis who received veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) after 120 minutes of cardiopulmonary resuscitation (CPR). This is the first adult case of cardiac arrest due to COVID-19-induced myocarditis supported by ECMO that fully recovered with normal neurological functions. The success of the treatment course with full recovery emphasized the potential role of ECMO in treating these patients.

[Reverse Takotsubo ou myocardite fulminante ? Succès de VA ECMO chez une patiente ayant une atteinte cardiaque liée COVID 19]. / Reverse TakoTsubo or Fulminant myocarditis ? Life saving VA ECMO in a COVID 19 patient.

A 45 years old female patient was admitted to our facility for COVID -19 infection complicated by fulminant cardiac injury and refractory cardiogemic shock. She had echographic findings of reverse takotsubo cardiomyopathy. She was successfully treated by VA-ECMO allowing complete revocery of the left ventricule function and weaning from support.

Phenotypic Heterogeneity of Fulminant COVID-19--Related Myocarditis in Adults.

BACKGROUND: Adults who have been infected with SARS-CoV-2 can develop a multisystem inflammatory syndrome (MIS-A), including fulminant myocarditis. Yet, several patients fail to meet MIS-A criteria, suggesting the existence of distinct phenotypes in fulminant COVID-19-related myocarditis. OBJECTIVES: This study sought to compare the characteristics and clinical outcome between patients with fulminant COVID-19-related myocarditis fulfilling MIS-A criteria (MIS-A+) or not (MIS-A-). METHODS: A monocentric retrospective analysis of consecutive fulminant COVID-19-related myocarditis in a 26-bed intensive care unit (ICU). RESULTS: Between March 2020 and June 2021, 38 patients required ICU admission (male 66%; mean age 32 ± 15 years) for suspected fulminant COVID-19-related myocarditis. In-ICU treatment for organ failure included dobutamine 79%, norepinephrine 60%, mechanical ventilation 50%, venoarterial extracorporeal membrane oxygenation 42%, and renal replacement therapy 29%. In-hospital mortality was 13%. Twenty-five patients (66%) met the MIS-A criteria. MIS-A- patients compared with MIS-A+ patients were characterized by a shorter delay between COVID-19 symptoms onset and myocarditis, a lower left ventricular ejection fraction, and a higher rate of in-ICU organ failure, and were more likely to require mechanical circulatory support with venoarterial extracorporeal membrane oxygenation (92% vs 16%; P < 0.0001). In-hospital mortality was higher in MIS-A- patients (31% vs 4%). MIS-A+ had higher circulating levels of interleukin (IL)-22, IL-17, and tumor necrosis factor-α (TNF-α), whereas MIS-A- had higher interferon-α2 (IFN-α2) and IL-8 levels. RNA polymerase III autoantibodies were present in 7 of 13 MIS-A- patients (54%) but in none of the MIS-A+ patients. CONCLUSION: MIS-A+ and MIS-A- fulminant COVID-19-related myocarditis patients have 2 distinct phenotypes with different clinical presentations, prognosis, and immunological profiles. Differentiating these 2 phenotypes is relevant for patients' management and further understanding of their pathophysiology.

Fulminant Myocarditis Following SARS-CoV-2 Infection: JACC Patient Care Pathways.

A 60-year-old woman with a past medical history of asthma presented with fulminant myocarditis 9 days after testing positive for SARS-CoV-2 and 16 days after developing symptoms consistent with COVID-19. Her hospital course was complicated by the need for veno-arterial extracorporeal membrane oxygenation, ventricular arrhythmias, and pseudomonas bacteremia. She ultimately recovered and was discharged to home with normal left ventricular systolic function. Thereafter, she developed symptomatic ventricular tachycardia, for which she received an implantable cardioverter-defibrillator and antiarrhythmic drug therapy.

COVID-19 Hasta Takibindeki ECMO Uygulamalarımız

Amaç: Ağır COVID-19 pnömonisi sonrası gelişen ARDS’de ekstrakorporeal membran oksijenasyon (ECMO) yöntemi, akciğer iyileşmesine zaman tanımak ve dolaşım dolaşım desteği sağlamak amacıyla kullanılmaktadır. Bu olgu serisi ile, yoğun bakımımızda uygulanan venö-venöz ve venöarteriyel ECMO tecrübesi paylaşılacaktır. Olgu: Yoğun bakımımızda altı VV-ECMO ve iki VA-ECMO olmak üzere toplam sekiz ECMO uygulaması yapıldı. Hastaların beşi erkek, üçü kadın hasta idi. Yaş ortalaması 49,1 (31-70) yıl olarak hesaplandı. Hastaların tümü aşısızdı. Komorbidite olarak bir hastada romatoid artrit, bir hastada multipl skleroz ve hipertansiyon, bir hastada astım, bir hastada hipertansiyon vardı. Hastaların tümü obezdi (VKÍ >30). Hastaların hepsinde prone pozisyonuna dirençli hipoksemi mevcuttu (PaO2/FiO2<70), ECMO kararı için hesaplanan Murray Skorları tüm hastalarda dört bulundu. Hastalara ortalama olarak entübasyonun dördüncü gününde ECMO başlandı. Hastaların altısına, izole olarak hipoksi mevcut olduğu için VV-ECMO;ikisine laktat artışı ve dirençli hipotansiyon olması nedeniyle VA-ECMO başlandı. Ortalama ECMO süresi 16 gün olarak (16 saat - 39 gün) bulundu. Standart olarak;VV-ECMO için, sağ juguler ven ve sağ femoral ven;VA-ECMO için sağ femoral arter ve sol femoral ven tercih edildi. Tüm hastaların ACT (activated clotting time) takipleri yapıldı ve 150-200 sn. arasında tutuldu. Bir hastada (taburcu olan) Heparin Induced Thrombocytopenia (HIT) gelişti. Bir hastada dirençli A. baummanii, bir hastada Aspergillus spp. üremesi tespit edildi. ECMO tedavisi altında takipte iken üç hastada anizokori tespit edildi. Bu hastalardan biri bilgisayarlı tomografiye transport için uygun olup yaygın parankimal kanama gösterildi (Şekil 1). Bir hastanın ECMO cihazı ani olarak kapandı, 45 dakika manuel olarak sirkülasyon sağlandı. En uzun süre ECMO tedavisi alan hasta taburcu edilirken, diğer yedi hasta vefat etti. Sonuç: ECMO uygulaması kendisine ait komplikasyonları olan, yüksek maliyetli, tecrübe ve eğitimli personel gerektiren bir yöntemdir. Bir tedavi seçeneği değil, iyileşmeye giden bir köprüdür. Hangi hastada, ne zaman uygulanması gerektiği tecrübe gerektiren bir uygulamadır. Geri döndürülebilir kliniği olan hastalarda doğru zamanda karar verilmesi önemlidir. (Turkish) [ FROM AUTHOR] Copyright of Turkish Journal of Intensive Care is the property of Galenos Yayinevi Tic. LTD. STI 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.)

Echocardiography for extracorporeal membrane oxygenation.

Extracorporeal membrane oxygenation (ECMO) provides advanced cardiopulmonary life support for patients in cardiac and/or respiratory failure. Echocardiography provides essential diagnostic and anatomic information prior to ECMO initiation, allows for safe and efficient ECMO cannula positioning, guides optimization of flow, provides a modality for rapid troubleshooting and patient evaluation, and facilitates decision-making for eventual weaning of ECMO support. Currently, guidelines for echocardiographic assessment in this clinical context are lacking. In this review, we provide an overview of echocardiographic considerations for advanced imagers involved in the care of these complex patients. We focus predominately on new cannulas and complex cannulation techniques, including a special focus on double lumen cannulas and a section discussing indirect left ventricular venting. Echocardiography is tremendously valuable in providing optimal care in these challenging clinical situations. It is imperative for imaging physicians to understand the pertinent anatomic considerations, the often complicated physiological and hemodynamic context, and the limitations of the imaging modality.

Characteristics and Outcomes of COVID-19 Patients Supported by Venoarterial or Veno-Arterial-Venous Extracorporeal Membrane Oxygenation.

OBJECTIVES: Cardiac injury has been reported in up to 20%-to-30% of patients with COVID-19, and severe disease can lead to cardiopulmonary failure. The role of mechanical circulatory support in these patients remains undetermined. The authors here aimed to determine the characteristics and outcomes of patients with COVID-19 requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) or veno-arterial-venous (VAV) ECMO support. DESIGN AND SETTING: A multicenter, retrospective case series. PARTICIPANTS: The cohort consisted of adult patients (18 years of age and older) with confirmed COVID-19 requiring VA ECMO or VAV ECMO support in the period from March 1, 2020, to April 30, 2021. Outcomes were recorded until July 31, 2021. MEASUREMENTS AND MAIN RESULTS: To show factors related to death during hospitalization, patients were grouped as survivors and nonsurvivors. Kaplan-Meier analysis was used to estimate 90-day in-hospital mortality. Overall, 37 patients from 12 centers comprised the study cohort. The median patient age was 44 years old (interquartile range [IQR], 35-52), and 12 (32%) were female patients. The duration of ECMO support ranged from 2-to-132 days. At the end of the follow-up period, 13 patients (35%) were discharged or transferred alive, and 24 patients (65%) died during the hospitalization. The cumulative in-hospital mortality at 90 days was 64% (95% confidence interval: 47-81). During the time from intubation to VA ECMO or VAV ECMO initiation (1 day [IQR 0-7.5] v 6 days [IQR 2.5-14], p = 0.0383), body mass index (32 [IQR 26-36] v 37 [IQR 33-40], p = 0.009), and baseline C-reactive protein (7.15 v 38.9 mg/dL, p = 0.009) were higher in those who expired. CONCLUSION: Only one-third of the patients with COVID-19 requiring VA ECMO or VAV ECMO survived to discharge. Close monitoring of at-risk patients with early initiation of ECMO with circulatory support may further improve outcomes.

Post-Infarction Ventricular Septal Rupture Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support as a Bridge to Definitive Therapy During the COVID-19 Pandemic.

Ventricular septal rupture (VSR) is a devastating complication of acute myocardial infarction (MI) and is often associated with cardiogenic shock. Although considered to be very rare in the reperfusion era, recent reports have demonstrated an increased frequency of post-MI VSR cases during the COVID-19 pandemic. Despite advances in surgical repair and management strategies over the past decades, mortality rate has remained high, especially in hemodynamically unstable patients. In VSR patients with cardiogenic shock, the use of mechanical circulatory support (MCS) could be used as a bridge to surgical intervention. We report a patient with VSR complicated by cardiogenic shock secondary to late presenting MI, managed successfully with venoarterial extracorporeal membrane oxygenation (VA-ECMO) as a bridge to surgical intervention.

Fulminant myocarditis: COVID or not COVID? Reinfection or co-infection?

We describe a unique case of fulminant myocarditis in a patient with presumed SARS-CoV-2 reinfection. Patient had initial infection 4 months backand had COVID-19 antibody at the time of presentation. Endomyocardial biopsy showed lymphocytic myocarditis, that is usually seen in viral myocarditis. The molecular diagnostic testing of the endomyocardial biopsy for cardiotropic viruses was positive for Parvovirus and negative for SARS-CoV-2. Authors highly suspect co-infection of SARS-CoV-2 and Parvovirus, that possibly triggered the immune cascade resulting in fulminant myocarditis. Patient was hemodynamically unstable with ventricular tachycardia and was supported on VA ECMO and Impella CP. There was impressive recovery of left ventricular function within 48 h, leading to decannulation of VA ECMO in 72 h. This unique case was written by the survivor herself.

Ventricular septal rupture and cardiogenic shock complicating STEMI during COVID-19 pandemic: An old foe re-emerges.

The COVID 19 pandemic resulted in a total reduction in the number of hospitalizations for acute coronary syndromes. A consequence of the delay in coronary revascularization has been the resurgence of structural complications of myocardial infarctions. Ventricular septal rupture (VSR) complicating late presenting acute myocardial infarction (AMI) is associated with high mortality despite advances in both surgical repair and perioperative management. Current data suggests a declining mortality with delay in VSR repair; however, these patients may develop cardiogenic shock while waiting for surgery. Available options are limited for patients with VSR who develop right ventricular failure and cardiogenic shock. The survival rate is very low in patients with cardiogenic shock undergoing surgical or percutaneous VSR repair. In this study we present two late presenting ST elevation MI patients who were complicated by rapidly declining hemodynamics and impending organ failure. Both patients were bridged with venoarterial extracorporeal membrane oxygenation (ECMO) to cardiac transplant.

Pulmonary Embolism in COVID-19 Treated with VA-ECLS and Catheter tPA.

BACKGROUND: Novel coronavirus 2019 (COVID-19) has been the focus of the medical world since being declared a pandemic in March 2020. While the pathogenesis and heterogeneity of COVID-19 manifestations is still not fully understood, viral evasion of cellular immune responses and inflammatory dysregulation are believed to play essential roles in disease progression and severity. CASE PRESENTATION: We present the first case of a patient with COVID-19 with massive pulmonary embolism treated successfully with systemic thrombolysis, VA-ECLS, and bail out catheter directed thrombolysis. He was discharged from the hospital after an eventful hospital course on therapeutic anticoagulation with warfarin. CONCLUSIONS: We present the first case of a patient with COVID-19 with massive pulmonary embolism (PE) treated successfully with systemic thrombolysis, VA-ECLS and bail out catheter directed thrombolysis. In our experience catheter directed thrombolysis comes with an acceptable bleeding risk despite use of mechanical circulatory support, particularly with meticulous attention to vascular access and dose response monitoring.

Acute Myocardial Infarction and Papillary Muscle Rupture in the COVID-19 Era.

Mechanical complications of acute myocardial infarction are infrequent in the modern era of primary percutaneous coronary intervention, but they are associated with high mortality rates. Papillary muscle rupture with acute severe mitral regurgitation is one such life-threatening complication that requires early detection and urgent surgical intervention. (Level of Difficulty: Beginner.).