key: cord-0984145-ctjardzf authors: McLean, Duncan J.; Henry, Mark title: Con: Veno-arterial ECMO Should not be Considered in Patients with COVID-19 date: 2020-11-18 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.11.029 sha: 8e619a7aff39f95098b91d2f5e82fea6a5550494 doc_id: 984145 cord_uid: ctjardzf nan The response to Coronavirus Disease 2019 (COVID-19) has involved a rapid global effort to understand the behavior of this disease, the range of clinical manifestations and effective treatment modalities. COVID-19 is caused by the coronavirus SARS-CoV-2, and was declared a pandemic on March 11 th 2020 by the World Health Organization. 1 Since the identification of symptoms in the first documented case in December 2019, there have been over 40 million confirmed cases and 1 million confirmed deaths worldwide as of the writing of this manuscript, 2 with an estimated mortality rate of 1.5 to 3.6%. 3 Clinically, COVID-19 is associated with a range of presentationsfrom asymptomatic to mild respiratory symptoms, through severe multiple organ failure. Moderate to severe disease is typically associated with lower respiratory symptoms, pulmonary failure and acute respiratory distress syndrome (ARDS). The mainstay of treating COVID-19 induced respiratory failure consists of supportive care, pharmacological treatment and protective mechanical ventilation. Cardiovascular shock in COVID-19 is poorly understood, but is likely due to one or more of several mechanisms: exacerbation of underlying cardiovascular disease, viral myocarditis, cytokine-induced myocardial stress, or right heart failure secondary to pulmonary venous thrombosis. [9] [10] [11] [12] [13] Cardiac complications of COVID-19, while not as common as respiratory symptoms, 14 do occur with some frequency and lead to increased morbidity and mortality. The rate of heart failure in hospitalized COVID-19 patients has been reported at 24%, 15 while clinically identified shock may occur in 9 to 17% of patients. 15, 16 Cardiac injury, as identified by highly elevated levels of high sensitivity troponin, is independently associated with increased mortality, 14, 17, 18 and patients with a history of hypertension, diabetes, and prior cardiac disease are at increased risk of cardiac injury while hospitalized with COVID-19. 14 Additionally, COVID-19 patients identified with cardiac injury have more complicated hospital courses, including an increased incidence of mechanical ventilation, ARDS, acute kidney injury and coagulation disorders. 14 Microvascular thrombosis leading to myocardial dysfunction has also been suggested as an etiology, however, direct pathological evidence of this appears lacking. 12 The incidence of right ventricular (RV) dysfunction in COVID-19 may be clinically underestimated, 19 with a reported frequency of right ventricular abnormalities of 32 to 39% in hospitalized patients. 20 ,21 This should not be surprising, given that prior to the COVID-19 pandemic, RV dysfunction has been shown to occur frequently (22-50%) in moderate to severe ARDS. 22 This association between RV dysfunction and ARDS may be attributed, at least in part, to elevated pulmonary vascular resistance with severe respiratory disease. Additionally, the high incidence of venous thromboembolism (23-27%) in COVID-19 is likely to induce RV dysfunction in a subset of affected individuals. 23,24 Finally, there have been clinical case reports of stress induced cardiomyopathy in COVID-19 patients. 25, 26 In addition to the increased mortality associated with cardiac injury in COVID-19, a few factors are worth considering prior to initiating VA-ECMO for COVID-19 patients in shock. First, preliminary numbers on the efficacy of VV-ECMO report a mortality of 57%, 27 which is already higher than the 35% mortality seen in the EOLIA (ECMO to Rescue Lung Injury in Severe ARDS) trial. 28 The exact reasons for this discrepancy are elusive, however the multiple organ involvement seen in severe SARS-CoV-2 infection is a probable etiology. When employing the more complicated cannulation strategies typically associated with VA-ECMO, we can expect the mortality rate will only rise. Since mortality with the utilization of VA-ECMO in the absence of COVID-19 is already higher, 29 we can expect COVID-19 VA-ECMO mortality to exceed at least 60%. The majority of COVID-19 patients presenting with cardiac complications have contraindications to VA-ECMO. The Extracorporeal Life Support Organization (ELSO) released a guidance document regarding the use of ECMO in COVID-19 patients. 30 Notable relative contraindications to the initiation of ECMO outlined in this document include advanced age, significant co-morbidities, and greater than 7 days on mechanical ventilation. Patients who fit into one or more of these categories can be expected to derive a diminished benefit from ECMO due to a higher risk of mortality, with multiorgan failure being the most common cause of mortality on VA-ECMO. 29 As noted previously, COVID-19 patients presenting with acute cardiac injury are in fact more likely to have underlying cardiovascular comorbidities and be of advanced age, 14 factors which no doubt contribute to an increased mortality risk, [15] [16] [17] [18] 21, [31] [32] [33] and, we argue, represent contraindications to the use of VA-ECMO. With the high prevalence of ARDS among hospitalized COVID-19 patients -33% of hospitalized Patients with SARS-Co-V-2019 have an increased risk of developing a hypercoagulable state, which manifests with the formation of both macro and microvascular thrombi. 45 Due to the extent of the pandemic, it is particularly important that resources are distributed in a manner that enables equitable access to the most effective therapies for as many patients as possible. Extracorporeal membrane oxygenation (ECMO) is extremely resource-intensive, diverting time, money, equipment and personnel that may be more effectively utilized to provide care for a greater number of critically ill patients. The Extracorporeal Life Support Organization (ELSO) guidelines support the use of VA-ECMO in cases where cardiogenic shock is refractory to medical therapies. However, the list of contraindications is comprehensive and includes advanced age, comorbidities and absence of an "exit strategy" post-ECMO. ECMO is a highly technical therapeutic modality, and outcomes have been demonstrated to be strongly correlated to the frequency with which ECMO is utilized by a hospital. Therefore, in the cases where VA-ECMO is being considered, in order to ensure the highest chance of a positive outcome the patient should be transferred to a center with an established ECMO program. However, this is problematic, as ECMO centers are already experiencing increased demand for VV-ECMO. Patients with COVID-19 who develop cardiovascular collapse are most effectively and efficiently treated with supportive medical therapies. Mechanical circulatory support with VA-ECMO is extremely resource-intensive, and is contraindicated in the majority of patients with COVID-19 due to the presence of multiorgan dysfunction. Right ventricular dysfunction due to severe respiratory failure is a common cause of late cardiovascular collapse in COVID-19, and represents end-stage disease not amenable to mechanical circulatory support. We recommend that VA-ECMO be reserved for the rare cases of patients with COVID-19 who present with isolated myocardial dysfunction, and be offered only in centers experienced at providing VA-ECMO. Real estimates of mortality following COVID-19 infection Cardiovascular Collapse in COVID-19 Infection: The Role of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO) Poor survival with extracorporeal membrane oxygenation in acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19): Pooled analysis of early reports Extracorporeal Membrane Oxygenation for Patients with COVID-19 in Severe Respiratory Failure Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry al: Description and proposed management of the acute COVID-19 cardiovascular syndrome Cardiovascular complications in COVID-19 Association of Cardiac Injury with Mortality in Hospitalized Patients with COVID-19 in Wuhan Clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study Clinical Characteristics of 138 Hospitalized Patients with Novel Coronavirus-Infected Pneumonia in Wuhan, China Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China Pulmonary and cardiac pathology in African American patients with COVID-19: an autopsy series from New Orleans Spectrum of Cardiac Manifestations in COVID-19: A Systematic Echocardiographic Study Incidence of thrombotic complications in critically ill ICU patients with COVID-19 Takotsubo Cardiomyopathy in COVID-19 COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality 2020/04/27. Sociedad Española de Cardiología Extracorporeal Membrane Oxygenation for Coronavirus Disease 2019-Induced Acute Respiratory Distress Syndrome Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: An analysis of the Extracorporeal Life Support Organization (ELSO) registry Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers Association of cardiovascular disease and 10 other pre-existing comorbidities with COVID-19 mortality: A systematic review and meta-analysis Cardiovascular Implications of Fatal Outcomes of Patients With Coronavirus Disease 2019 (COVID-19) Incidence of ARDS and outcomes in hospitalized patients with COVID-19: A global literature survey Pulmonary hypertension and right ventricular involvement in hospitalised patients with COVID-19 Pulmonary vascular disease Prognostic Value of Right Ventricular Longitudinal Strain in Patients With COVID-19 First case of COVID-19 complicated with fulminant myocarditis: a case report and insights Prevalence and prognosis of cor pulmonale during protective ventilation for acute respiratory distress syndrome Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score Cardiac Involvement in a Patient with Coronavirus Disease 2019 (COVID-19) Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin Myocardial localization of coronavirus in COVID-19 cardiogenic shock First Successful Treatment of Coronavirus Disease 2019 Induced Refractory Cardiogenic plus Vasoplegic Shock by Combination of Percutaneous Ventricular Assist Device and Extracorporeal Membrane Oxygenation: A Case Report Extracorporeal Membrane Oxygenation for Coronavirus Disease Coagulopathy of Coronavirus Disease Review of venoarterial extracorporeal membrane oxygenation and development of intracardiac thrombosis in adult cardiothoracic patients Thrombosis in Hospitalized Patients with COVID-19 in a New York City Health System