Veno-Venous Extracorporeal Membrane Oxygenation (V-V ECMO) as a Bridge to Lung Transplantation Following Severe Covid-19 Infection

Abstract

Introduction The Coronavirus Disease 2019 (COVID-19) has proven to be the most infectious and deadly respiratory virus since the 1918 H1N1 influenza A pandemic. According to the World Health Organization (WHO), COVID-19 has caused over 62 million infections and more than 1.4 million deaths worldwide in the first year of the pandemic. This case report depicts the clinical course of a patient with severe acute respiratory distress syndrome (ARDS) caused by COVID-19, requiring VV-ECMO and bilateral orthotopic lung transplantation (BOLT). Case Description R.R. was a 57-year-old triathlete with history of smoking 20 years ago, anxiety, and depression. He initially presented to an outside hospital (OSH) with symptoms of fever and dyspnea and was admitted to the intensive care unit (ICU) due to increasing oxygen requirements on BiPAP seven days later. Notably, two subsequent COVID tests resulted negative. On hospital day (HOD) 28, he necessitated urgent cannulation for VV-ECMO and was transferred to our institution for further management. R.R.'s ICU course was characterized by a progressive decline of respiratory function. Chest computed tomography (CT) revealed severe bullous emphysema and interstitial fibrosis. The patient developed right ventricular (RV) failure warranting treatment with inhaled nitric oxide and diuresis. Given the overall clinical status, he underwent expedited work-up and listing for lung transplantation. On HOD 32 he required intubation for worsening hypoxemia despite ECMO support with flows of 4.5 L/min, sweep of 4 L/min and circuit FiO2 of 100% with maximum lung protective ventilator support. Notably, a repeat COVID test was positive. Several days later, he underwent a tracheostomy. He continued to experience refractory hypoxia and hypercarbia, necessitating deep sedation, paralysis, and ECMO sweep of 14 L/min on the night preceding his BOLT. Post-operative course was largely unremarkable. His tracheostomy was decannulated on HOD 52 and he was discharged to rehab on HOD 59. The patient spent 17 days in rehab and was discharged home. Discussion In this case, an active triathlete without significant comorbidities developed severe pulmonary fibrosis leading to end stage lung disease from COVID-19. The vast majority of patients infected with COVID-19 have mild to moderate disease. However, patients with severe disease requiring mechanical ventilation have a mortality rate of up to 20-25%. The proportion of patients who require ECMO and lung transplantation is small. This case illustrates the merit of urgent evaluation for ECMO candidacy and consideration of lung transplantation for selected individuals in this small cohort of patients.