Bedside Right Atrium to Left Atrium ECMO Cannulation: A Novel Approach in Patients With Severe ARDS Due to Covid-19

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) can provide life-saving treatment of adult respiratory distress syndrome (ARDS) complicating COVID-19 infection. We hypothesized that a modified ECMO (right to left atrium [RA-LA] cannulation with TandemHeart cannula and an oxygenator;TandemHeart ECMO) might be superior to conventional veno-venous (VV)-ECMO. Methods: A total of 19 patients with COVID-19 underwent ECMO at Princeton Hospital. We compared in-hospital complications and short-term outcomes between patients with VV ECMO vs. RA-LA ECMO. VV-ECMO was initiated in the cath lab, while RA-LA ECMO was initiated bedside using intracardiac echo guidance. We used Fisher’s exact test for mortality and Student’s t-test for other variables. Results: Between March and September 2020, 19 patients underwent ECMO cannulation. Out of 19 patients, 5 patients had beside TandemHeart ECMO (we performed bedside ICU ECMO procedure in 5 patients, 3 males and 2 females). We placed a 21F LA cannula (TandemHeart, TandemHeart, Pittsburgh, PA) via the right common femoral vein (CFV) and a 25F RA cannula (Edwards, Irvine, CA) through the left CFV. Both the oxygenator and pump were also a TandemHeart system. The median duration of ECMO was 16 days (range 7 to 19 days) for RA-LA ECMO compared to 26 days (range 12-81 days) for conventional VV-ECMO (p<0.02). The mean number of blood transfusions was 10.4±1.6 vs. 21.8±7.1 units, p<0.0001. One patient in the TandemHeart ECMO arm required dialysis, while 8/14 patients on VV-ECMO required dialysis, p=0.1. Intensive care unit (ICU) length of stay was shorter in the RA-LA ECMO group compared to VV ECMO (25.8±7.4 vs. 3.67±14.1 days, p<0.05). A total of 6/14 (42.8%) patients in the VV-ECMO vs. 0/5 (0%) in the RA-LA ECMO died in the hospital. However, this was not statistically significant (p=0.2). No major procedural complications, including tamponade occurred in the RA-LA arm despite using bedside ICE without fluoroscopy. Conclusion: Bedside percutaneous RA-LA cannulation was feasible and safe and was associated with significantly shorter ECMO and ICU days among COVID-19 patients presenting with ARDS. This strategy has the potential benefit of providing complete cardiopulmonary support in patients with ARDS. However, larger studies are needed to confirm its role in COVID-19 infections and potentially other ARDS scenarios.