VV-ECMO Support Research Articles

P87: Fracture Of A Dual Lumen Protekduo Cannula With Ventricular Perforation And Tamponade In A Recovery COVID-19 Patient

Background: In the absence of formal registry data anecdotal reports of cannula complications provide the only mechanism of risk assessment in the extended use of short term mechanical circulatory support devices. We report an unrecognized cannula fracture with perforation of the right ventricular apex and subsequent tamponade at the time of de-cannulation. Methods and Results: Patient is a 38 yo AAF with a history of asthma diagnosed with COVID 19 (nasal PCR) and admitted to an OSH with hypoxia (O2 sat 70%) and progressive dyspnea on exertion requiring HFNC and subsequent deployment of a right internal jugular 29 Fr Protek-DUO double lumen cannula with in-line oxygenator for venovenous ECMO respiratory support. After 36 days of VV ECMO support and mechanical ventilation, the patient was transferred with a diagnosis of COVID ARDS for transplant evaluation. Fourteen days post-transfer the patient was ambulatory and no longer required mechanical ventilation. No flow related issues were noted during the entire period of ECMO support (flow 2.8 to 3.4 L/min, delta P 20 mmHg or less, single oxygenator exchange on ECMO day 38). On ECMO day 67 the patients CxR was clear (Figure 1) and the RIJ cannula was removed without complication. Approximately two minutes after cannula removal the patient became unresponsive with tachycardia and hypotension (SBP 60 mmHg) which initially responded to volume resuscitation. With progressive loss of systolic blood pressure chest compressions were started with complete hemodynamic collapse. A transthoracic ECHO suggested tamponade and the chest was opened at the bedside demonstrating a chronic appearing hematoma with blood extravasation at the apex of the right ventricle (Figure 2). Bleeding was controlled with a single prolene stitch. Subsequent examination of the cannula demonstrated a fracture in the wire reinforced cannula at the point where the catheter transitioned from the apical RV into the RVOT (Figure 3). Conclusion: Given the progressive pulmonary hypertension frequently seen with prolonged COVID ECMO support, the RA to PA dual-lumen cannula has proven an effective MCS strategy (1) with survival advantage when compared to standard VV ECMO support (2). The Protek-DUO cannula was not designed for prolonged ambulatory MCS (> 60 days). Given the recent report of a seemingly identical cannula fracture event (3), clinicians should be aware of the potential for cannula fracture over time. Literature Cited (1) Mustafa AK, et al. (2020) ECMO for patients with COVID-19 in severe respiratory failure. JAMA Surg 155(10):990-992. (2) Saeed O, et al (2022) Outcomes by cannulation method for venovenous ECMO during COVID-19: a multicenter retrospective study. 46(8):1659-1668. doi: 10.1111/aor.14213. (3) Odish MF, et al (2022) Fracture right atrial-pulmonary artery cannula (Protek-DUO) in a 164-day extracorporeal membrane oxygenation bridge to lung transplant. doi: 10.1097/MAT.0000000000001879. Online ahead of print.

A case series evaluating the effect of esmolol therapy to treat hypoxemia in COVID-19 patients on VV-ECMO.

When COVID-19 ARDS abolishes pulmonary function, VV-ECMO can provide gas exchange. If oxygenation remains insufficient despite maximal VV-ECMO support, the addition of esmolol has been proposed. Conflict exists, however, as to the oxygenation level which should trigger beta-blocker initiation. We evaluated the effect of esmolol therapy on oxygenation and oxygen delivery in patients with negligible native lung function and various degrees of hypoxemia despite maximal VV-ECMO support. We found that, in COVID-19 patients with negligible pulmonary gas exchange, the generalized use of esmolol administration to raise arterial oxygenation by slowing heart rate and thereby match native cardiac output to maximal attainable VV ECMO flows actually reduces systemic oxygen delivery in many cases.

Changes in Therapy and Outcome of Patients Requiring Veno-Venous Extracorporeal Membrane Oxygenation for COVID-19.

Coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation (vv-ECMO) is related with poor outcome, especially in Germany. We aimed to analyze whether changes in vv-ECMO therapy during the pandemic were observed and lead to changes in the outcome of vv-ECMO patients. All patients undergoing vv-ECMO support for COVID-19 between 2020 and 2021 in a single center (n = 75) were retrospectively analyzed. Weaning from vv-ECMO and in-hospital mortality were defined as primary and peri-interventional adverse events as secondary endpoints of the study. During the study period, four infective waves were observed in Germany. Patients were assigned correspondingly to four study groups: ECMO implantation between March 2020 and September 2020: first wave (n = 11); October 2020 to February 2021: second wave (n = 23); March 2021 to July 2021: third wave (n = 25); and August 2021 to December 2021: fourth wave (n = 20). Preferred cannulation technique changed within the second wave from femoro-femoral to femoro-jugular access (p < 0.01) and awake ECMO was implemented. Mean ECMO run time increased by more than 300% from 10.9 ± 9.6 (first wave) to 44.9 ± 47.0 days (fourth wave). Weaning of patients was achieved in less than 20% in the first wave but increased to approximately 40% since the second one. Furthermore, we observed a continuous numerically decrease of in-hospital mortality from 81.8 to 57.9% (p = 0.61). Preference for femoro-jugular cannulation and awake ECMO combined with preexisting expertise and patient selection are considered to be associated with increased duration of ECMO support and numerically improved ECMO weaning and in-hospital mortality.

Transfer of Veno-venous Extracorporeal Membrane Oxygenation Patients With COVID-19 Associated Acute Respiratory Distress Syndrome.

Interhospital transport of acute respiratory distress syndrome (ARDS) patients bears transport-associated risks. It is unknown how interhospital extracorporeal membrane oxygenation (ECMO) transfer of COVID-19 patients by mobile ECMO units affects ARDS mortality. We compared the outcome of 94 COVID-19 patients cannulated in primary care hospitals and retrieved by mobile ECMO-teams to that of 84 patients cannulated at five German ECMO centers. Patients were recruited from March 2020 to November 2021. Twenty-six transports were airborne, 68 were land-based. Age, sex, body-mass-index, Simplified Acute Physiology Score (SAPS) II, days invasively ventilated, and P/F-Ratio before ECMO initiation were similar in both groups. Counting only regional transports (≤250 km), mean transport distance was 139.5 km ± 17.7 km for helicopter (duration 52.5 ± 10.6 minutes) and 69.8 km ± 44.1 km for ambulance or mobile intensive care unit (duration 57.6 ± 29.4 minutes). Overall time of vvECMO support (20.4 ± 15.2 ECMO days for transported patients vs. 21.0 ± 20.5 for control, p = 0.83) and days invasively ventilated (27.9 ± 18.1 days vs. 32.6 ± 25.1 days, p = 0.16) were similar. Overall mortality did not differ between transported patients and controls (57/94 [61%] vs. 51/83 [61%], p = 0.43). COVID-19 patients cannulated and retrieved by mobile ECMO-teams have no excess risk compared with patients receiving vvECMO at experienced ECMO centers. Patients with COVID-19-associated ARDS, limited comorbidities, and no contraindication for ECMO should be referred early to local ECMO centers.

Multiple-site decontamination to prevent acquired infection in patients with veno-venous ECMO support

BackgroundAcute distress respiratory syndrome (ARDS) patients with veno-venous extra corporeal membrane oxygenation (ECMO) support are particularly exposed to ECMO-associated infection (ECMO-AI). Unfortunately, data regarding AI prophylaxis in this setting are lacking. Selective decontamination regimens decrease AI incidence, including ventilator-associated pneumonia (VAP) and bloodstream infection (BSI) in critically ill patients. We hypothesized that a multiple-site decontamination (MSD) regimen is associated with a reduction in the incidence of AI among VV-ECMO patients.MethodsWe conducted a retrospective observational study in three French ECMO referral centers from January 2010 to December 2021. All adult patients (> 18 years old) who received VV-ECMO support for ARDS were eligible. In addition to standard care (SC), 2 ICUs used MSD, which consists of the administration of topical antibiotics four times daily in the oropharynx and the gastric tube, once daily chlorhexidine body-wash and a 5-day nasal mupirocin course. AIs were compared between the 2 ICUs using MSD (MSD group) and the last ICU using SC.ResultsThey were 241 patients available for the study. Sixty-nine were admitted in an ICU that applied MSD while the 172 others received standard care and constituted the SC group.There were 19 ECMO-AIs (12 VAP, 7 BSI) in the MSD group (1162 ECMO-days) compared to 143 AIs (104 VAP, 39 BSI) in the SC group (2376 ECMO-days), (p < 0.05 for all infection site). In a Poisson regression model, MSD was independently associated with a lower incidence of ECMO-AI (IRR = 0.42, 95% CI [0.23–0.60] p < 0.001). There were 30 multidrug resistant microorganisms (MDRO) acquisition in the SC group as compared with two in the MSD group (IRR = 0.13, 95% CI [0.03–0.56] p = 0.001). Mortality in ICU was similar in both groups (43% in the SC group vs 45% in the MSD group p = 0.90). Results were similar after propensity-score matching.ConclusionIn this cohort of patients from different hospitals, MSD appeared to be safe in ECMO patients and may be associated with improved outcomes including lower ECMO-AI and MDRO acquisition incidences. Since residual confounders may persist, these promising results deserve confirmation by randomized controlled trials.

Case Report: When Enough is not Enough… Treating Refractory Hypoxemia

Herein we report a case of a 43 year old immunocompromised male, post renal transplant, with Adult Respiratory Distress Syndrome (ARDS), secondary to Severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), who required Veno-Venous Extra Corporeal Membrane Oxygenation (VV ECMO), with the unique configuration of double oxygenators. Despite invasive ventilatory support and maximum conventional VV ECMO support, he had persistent refractory hypoxemia. At this point, it was deemed necessary to attempt an adjuvant intervention to improve his oxygenation and hence the decision was made, to add another oxygenator to the existing ECMO circuit. His oxygenation parameters improved after the addition of the second oxygenator. The patient improved gradually and we continued to wean his ECMO settings. He was eventually DE cannulated after 34 days on ECMO. We believe that this is the first case where two oxygenators were placed in parallel, in a single circuit, for a SARS COV-2 patient with refractory hypoxemia. The addition of an oxygenator in parallel was successful in improving oxygenation and more importantly allowed us to continue with ultra-protective lung ventilation. The patient provided informed consent for scientific publication.

Comparison of Sedation and Analgesia Requirements in Patients With SARS-CoV-2 Versus Non-SARS-CoV-2 Acute Respiratory Distress Syndrome on Veno-Venous ECMO.

Increased analgosedation requirements have been described in patients with acute respiratory distress syndrome (ARDS) on extracorporeal membrane oxygenation (ECMO) support due to unique pharmacokinetic challenges. There is a paucity of data comparing sedation requirements in patients on ECMO for ARDS secondary to SARS-CoV-2 versus other etiologies of respiratory failure. To compare sedation and analgesia requirements in adult patients with SARS-CoV-2 versus non-SARS-CoV-2 ARDS requiring veno-venous (VV) ECMO support. We performed a retrospective cohort study of adult patients receiving sedation and analgesia on VV-ECMO support. Patients were excluded if cannulated at an outside hospital for greater than 24 hours, expired within 48 hours of ECMO cannulation, or received neuromuscular blocking agents for greater than 7 consecutive days following ECMO cannulation. We evaluated 108 patients on VV-ECMO support, including 44 with non-SARS-CoV-2 ARDS and 64 with SARS-CoV-2 ARDS. The median daily dexmedetomidine requirements were significantly higher in the SARS-CoV-2 cohort (16.7 vs 13.4 mcg/kg/day, P = 0.03), while the median propofol daily requirements were significantly higher in the non-SARS-CoV-2 cohort (40.3 vs 53.5 mg/kg/day, P < 0.01). There was no difference in daily requirements of opioids, benzodiazepines, and ketamine between groups. Use of adjunct agents to facilitate weaning was significantly higher in the SARS-CoV-2 cohort (78.1% vs 43.2%, P < 0.01). Patients with ARDS on VV-ECMO support require multiple analgosedative agents with concomitant use of nonparenteral adjunct agents. Further studies are needed to evaluate optimal analgosedation strategies in patients on ECMO support.

894: PENTOBARBITAL FOR SEDATION OF ADULTS RECEIVING EXTRACORPOREAL MEMBRANE OXYGENATION FOR COVID-19

Introduction: Sedation for ventilated patients with COVID-19 is challenging given the severity and duration of the disease. Complicating this is the introduction of extracorporeal membrane oxygenation (ECMO) for patients with refractory respiratory failure. An ECMO circuit can meaningfully alter drug pharmacokinetics by sequestering drug, increasing the volume of distribution, and altering clearance. Many common sedatives are known to be significantly impacted, thus altering standard dosing. In circumstances warranting deep sedation, such as ARDS, clinicians need a wide array of sedatives and analgesics available when managing patients receiving ECMO support. To our knowledge, no studies have assessed the use of pentobarbital as a sedative in adult patients receiving ECMO support for severe ARDS. We aimed to characterize the use of pentobarbital infusions as part of a multi-modal sedation regimen in adult patients with COVID-19 who were receiving ECMO. Methods: Adults with COVID-19 who were receiving both pentobarbital and VV-ECMO support between March 2020 and December 2021 were included. The primary outcome was change in the dose of concomitant sedatives at 24- and 48-hours post-initiation of pentobarbital. Secondary outcomes included depth of sedation, ventilator synchrony, mean arterial pressure (MAP), and vasopressor doses in norepinephrine equivalents. Additionally, we assessed for adverse drug reactions (ADRs) which included hypotension and transaminitis. Results: Five patients were included. All patients were initiated on a pentobarbital infusion for the indication of ventilator dyssynchrony. Patients received pentobarbital at an initial rate of 1 mg/kg/hr and infusion rates ranged between 0.5 – 2 mg/kg/hr. Following pentobarbital initiation, all patients became synchronous with the ventilator and doses of continuous sedative infusions decreased. Additionally, the total number and daily dose of rescue sedative medications decreased following pentobarbital initiation. ADRs were common and included hypotension (60%) and transaminitis (20%). Conclusions: A pentobarbital infusion can be used as part of a multimodal sedation regimen for patients requiring high doses of sedatives to achieve ventilator synchrony.

281: BURN TRAUMA, INHALATION INJURY, ECMO SUPPORT, AND DEFINING FUTILITY

Introduction: Extracorporeal membrane oxygenation (ECMO) in pulmonary failure bridges to recovery in severe inhalation injury but is challenging and can be a “bridge to nowhere”, when recovery does not occur. Evaluating ECMO support daily is vital for care planning, defining futility and de-escalation as appropriate for natural death. We present a patient with severe burn trauma/inhalation injury and profound respiratory failure needing V-V ECMO for stabilization. After several days of ECMO he developed hemolysis, acidemia and coagulopathy and care was de-escalated. Description: A 32-year-old male presented with widespread 50% full thickness burns from a car fire. He was found obtunded outside the vehicle and urgently transported to nearest facility for initial triage. He was intubated for airway protection and transferred to a comprehensive burn center for further management. COHB at OSH was 11, he received initial fluid resuscitation. Based on mechanism on injury, elevated COHB, soot in airway and altered mentation, he was given cyanokit in ED. Hospital course was complicated by profound respiratory failure requiring urgent initiation of VV-ECMO support. He underwent multiple burn debridements and tracheostomy for prolonged ventilator dependence. He also underwent allografting and placement of biodegradable temporizing matrix. Despite daily wound care and antibiotics, his developed severe sepsis/septic shock, coagulopathy, hypothermia and acidosis on VV-ECMO. Since his condition was declining refractory to maximal support, it was determined to be futile and ECMO support was discontinued. He died shortly thereafter. Team communicated with family who understood interventions and outcome. Discussion: ECMO is resource intensive, invasive and risks devastating complications. Implementation is complex, adding to burden of care for patient and family and indicated as a bridge to recovery in severe respiratory failure. In this patient, ECMO initiation criteria were met. When their clinical status declined, with therapeutic complications and refractory illness progression, futility was quickly identified and care de-escalated allowing a more comfortable, dignified death. This is an appropriate care template when patients are encountered as described and futility is evident.

ANALYSIS OF ESTONIAN ECMO REGISTRY DATA OF COVID OUTBRAKE 2020 TO 2022

We launched Estonian nationwide ECMO registry in 2021 including data of all patients supported with ECLS in both ECMO centres - Tartu University Hospital and North Estonia Medical Centre. For the completeness of Registry all retrospective data were added back from 2009. Dataset includes patient demographics, diagnoses, ICU-, hospital- and 12 month survival, ECLS details and complications. To date, the registry contains data of 301 patients. Since January 2020, 65 confirmed Covid-19 patients have received ECLS support: VV-ECMO was used 55, ECCO2R 7, VA support 1 and eCPR in 2 instances. The primary outcome in our analysis was in-hospital death. Secondary outcome was to compare in-hospital mortality and length of stay of Covid-confirmed patients to the 54 non-Covid ARDS patients treated with VV-ECMO. <b>Findings:</b> Data for 55 adult patients with Covid-19 who received VV-ECMO support were available and included to this study. Of these 19(34.5%) were discharged home or to rehabilitation centre, 6(10.9%) were still in hospital at a time of analysis and 22(40.0%) died. One patient was bridged to successful lung transplantation. We also supported two pregnant patients with good maternal and neonatal outcomes. Comparing hospital mortality of Covid-confirmed cases to 54 non-Covid adult ARDS patients, hospital mortality was similar between the groups - 44.9% (22/49) and 46.2% (34/52) respectively. For those who were discharged alive, hospital LOS was longer for Covid-confirmed cases compared to non-Covid patients (mean 59 vs 50 days, respectively). <b>Interpretation:</b> In patients with Covid-19 who received ECMO, observed outcome supports existing recommendations to consider use of ECMO in refractory Covid-19 related respiratory failure when performed in experienced centres. Registry can also be used to coordinate ECMO beds, equipment and personnel as resources become constrained. We constantly monitored availability of ECMO beds and agreed on common indications for VV ECMO in covid patients. Further analysis will concentrate on 12 month survival and functional outcome.

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

ROLE OF VENOVENOUS EXTRACORPOREAL MEMBRANE OXYGENATION IN SALVAGE THERAPY FOR CENTRAL AIRWAY OBSTRUCTION: A CASE REPORT

Feasibility of transbronchial lung cryobiopsy in patients with veno-venous extracorporeal membrane oxygenation support.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is essential life support in patients with severe acute hypoxaemic respiratory failure. However, biopsies should be considered for some patients with unknown aetiology. This study aims to evaluate the feasibility of transbronchial lung cryobiopsy (TBLC) in such patients. All patients with acute hypoxaemic respiratory failure of unknown aetiology who underwent TBLC with VV-ECMO support were retrospectively reviewed. Patients' characteristics, ventilation settings, procedure parameters, complications, pathological diagnosis and survival were summarised and analysed. Eight female and five male patients with VV-ECMO support underwent TBLC. The median age was 58 (interquartile range (IQR) 38-67) years old. Concurrent diseases were present in 10 of the 13 patients, seven of which were immunosuppressed. The median time between biopsy and VV-ECMO establishment was 2.0 (IQR 0.5-6.5) days. No patient died from the procedure. Neither pneumothorax nor severe bleeding occurred in any of the patients. Five of the 13 patients experienced moderate bleeding, and all bleeding events were successfully controlled with prophylactic balloon blockers. Pathological diagnosis by TBLC was obtained in all patients, and the diagnosis of diffuse alveolar damage was made in nine of them. In patients with VV-ECMO support, the TBLC procedure is generally safe when standardised bleeding prophylaxis is in place. TBLC contributes to identifying underlying aetiologies in patients with acute hypoxaemic respiratory failure of unknown aetiology.

Blood purification therapy in patients with severe COVID-19 requiring veno-venous ECMO therapy: A retrospective study.

Patients with severe manifestations of COVID-19 might exhibit characteristics of a sepsis-like syndrome that can progress to multiple organ failure and ultimately death. Underlying mechanism have been explored and suggest a profound dysregulation of the immune system associated with hyperinflammation, hemodynamic instability and respiratory failure. Besides standard intensive care treatment, approaches modulating the dysregulated immune response, such as CytoSorb hemoadsorption, have been used. However, data of ECMO-dependent patients in comparison to a control cohort remain scarce. Included were 26 critically ill COVID-19 patients requiring high-flow veno-venous extracorporeal membrane oxygenation (high-flow VV ECMO) therapy due to severe acute respiratory distress syndrome (ARDS), of whom 16 were additionally treated with an extracorporeal hemoadsorption device, and compared to a control group of 10 patients. Assessed were levels of inflammatory markers, vasopressor requirements, oxygenation parameters, as well as clinically relevant outcome variables. Data were prospectively recorded and retrospectively analyzed. Treatment with the applied multimodal therapy approach resulted in a stabilization in hemodynamics, a control of the hyperinflammatory response as evidenced by a significant reduction in inflammatory mediators, as well as a marked improvement in lung function. No device related adverse events were observed while treatment appeared safe and feasible. Treatment of a critically ill COVID-19 ARDS patients with combined VV ECMO support and hemoadsorption therapy led to a rapid and sustained hemodynamic stabilization, a control of the uncontrolled inflammatory response and an improvement in oxygenation. Given these signals pointing toward a patient-oriented benefit of extracorporeal hemoadsorption therapy in those patients, future controlled, randomized studies should focus on the investigation of the appropriate timing and dosing of this promising treatment modality.

COV2: Lung Transplantation Promotes Survival In Patients with COVID-19 ARDS Who Require Extended Duration of VV ECMO support

COV2: Lung Transplantation Promotes Survival In Patients with COVID-19 ARDS Who Require Extended Duration of VV ECMO support

Assessing the SAfety and FEasibility of bedside portable low-field brain Magnetic Resonance Imaging in patients on ECMO (SAFE-MRI ECMO study): study protocol and first case series experience

BackgroundTo assess the safety and feasibility of imaging of the brain with a point-of-care (POC) magnetic resonance imaging (MRI) system in patients on extracorporeal membrane oxygenation (ECMO). Early detection of acute brain injury (ABI) is critical in improving survival for patients with ECMO support.MethodsPatients from a single tertiary academic ECMO center who underwent head CT (HCT), followed by POC brain MRI examinations within 24 h following HCT while on ECMO. Primary outcomes were safety and feasibility, defined as completion of MRI examination without serious adverse events (SAEs). Secondary outcome was the quality of MR images in assessing ABIs.ResultsWe report 3 consecutive adult patients (median age 47 years; 67% male) with veno-arterial (n = 1) and veno-venous ECMO (n = 2) (VA- and VV-ECMO) support. All patients were imaged successfully without SAEs. Times to complete POC brain MRI examinations were 34, 40, and 43 min. Two patients had ECMO suction events, resolved with fluid and repositioning. Two patients were found to have an unsuspected acute stroke, well visualized with MRI.ConclusionsAdult patients with VA- or VV-ECMO support can be safely imaged with low-field POC brain MRI in the intensive care unit, allowing for the assessment of presence and timing of ABI.

Lung Transplant for Patients with COVID-19 Bridged with VV ECMO: Initial Experience

PurposeDuring the COVID-19 pandemic, veno-venous Extracorporeal Membrane Oxygenation (VV ECMO) has been used extensively for respiratory failure refractory to conventional mechanical ventilation (MV) and rescue maneuvers. However, the worldwide experience with COVID-19 patients undergoing lung transplant (LTx) with pre-LTx VV ECMO support is limited. Therefore, we sought to report our institution's early experience with COVID-19 patients who underwent LTx after VV ECMO.MethodsWe retrospectively identified 5 COVID-19 patients who underwent LTx after VV ECMO support. Patients were required to have a negative nasopharyngeal swab and a negative bronchoalveolar lavage for COVID-19 prior to LTx listing. We analyzed preoperative and operative characteristics, details of VV ECMO support and early post-transplant outcomes.ResultsThe mean age of our cohort was 50 years (range 39-57 years) and all patients were male. Mean recipient BMI was 30 (range 22-37). Mean duration of VV ECMO pre-Ltx was 60 days (range 44-72 days). At the time of the LTx operation, 60% (3/5) of patients were on VV ECMO, 20% (1/5) were on mechanical ventilation (MV), and 20% (1/5) were on supplemental oxygen only. Preoperatively, 80% (4/5) had acute kidney injury and 20% (2/5) were on dialysis. LTx was performed via clamshell approach with intraoperative venoaterial ECMO support in all cases. For 60% (3/5) patients, VV ECMO support was continued after LTx and discontinued on postoperative days 0, 1 and 6, respectively. All-cause mortality was 40% (2/5), related to sepsis and multi-organ failure, and both deaths occurred an average of 115 days post-LTx. Mean length of stay for surviving patients was 59 days (range 22-117). In the first 3 months postop-LTx, grade A2 acute cellular rejection was noted in 2 patients, A1 in 2 patients, and antibody-mediated rejection in 1 patient.ConclusionOur early experience with LTx for COVID-19 patients supported with VV ECMO support is notable for 1) prolonged VV-ECMO duration and significant morbidity pre-LTx, and 2) early mortalities related to sepsis and multiple organ failure. These data highlight a uniquely complex patient population that carries high risk of multi-organ failure and other comorbidities dictating careful selection for transplant.

Therapeutic Drug Monitoring-Guided Combination Alemtuzumab and Plasmapheresis for Refractory Acute Lung Allograft Dysfunction Rescue Therapy

<h3>Introduction</h3> Alemtuzumab is a potent immunosuppressive that has been used for treatment of refractory acute lung allograft dysfunction (ALAD); however, its use in combination with plasmapheresis (PP) after lung transplantation has not been described. <h3>Case Report</h3> A 35 year old female underwent bilateral lung transplantation for WHO group 1 pulmonary arterial hypertension secondary to limited scleroderma. Induction consisted of basiliximab and steroids, initial maintenance included steroids, mycophenolate and tacrolimus. Post operative day (POD) 5 she developed progressive respiratory failure requiring VV-ECMO support. Infectious and HLA DSA workup were negative; however, CT and bronchoscopic findings were suggestive of antibody mediated rejection (AMR). A presumptive diagnosis of non-HLA AMR was made. Treatment consisted of PP, ATG, IVIg and rituximab. After transient improvement, on POD 47 a second course of ATG and steroid pulse with taper was required due to progressive ALAD. By POD 66 there was further deterioration of graft function. Alemtuzumab rescue was administered with PP for elimination of effector immune cells and treatment of presumed persistent non-HLA AMR. In the absence of PP alemtuzumab is known to exceed concentrations that inhibit reconstitution (>0.7 ug/mL) for several weeks. To ensure PP did not impair prolonged cytoreduction, or alemtuzumab-induced tolerogenicity, plasma monitoring of alemtuzumab was used to allow for redosing if the level fell below 0.7 ug/mL after PP. Elimination was not significantly altered after redosing (figure 1). Her ALAD stabilized although she developed severe restrictive CLAD. There were no infectious complications. 153 days following alemtuzumab administration, after completing inpatient prehabilitation, she was successfully retransplanted. <h3>Summary</h3> Therapeutic drug monitoring can be used to safely readminister alemtuzumab when used in combination with PP for rescue of refractory ALAD.

One-Year Outcomes With Venovenous Extracorporeal Membrane Oxygenation Support for Severe COVID-19

BackgroundSevere coronavirus disease 2019 (COVID-19) can cause acute respiratory failure requiring mechanical ventilation. Venovenous (VV) extracorporeal membrane oxygenation (ECMO) has been used in patients in whom conventional mechanical ventilatory support has failed. To date, published data have focused on survival from ECMO and survival to discharge. In addition to survival to discharge, this study reports 1-year follow-up data for patients who were successfully discharged from the hospital. MethodsA single-institution, retrospective review of all patients with severe COVID-19 who were cannulated for VV-ECMO between March 10, 2020 and May 1, 2020 was performed. A multidisciplinary ECMO team evaluated, selected, and managed patients with ECMO support. The primary outcome of this study was survival to discharge. Available 1-year follow-up data are also reported. ResultsA total of 30 patients were supported with VV-ECMO, and 27 patients (90%) survived to discharge. All patients were discharged home or to acute rehabilitation on room air, except for 1 patient (3.7%), who required supplemental oxygen therapy. At a median follow-up of 10.8 months (interquartile range [IQR], 8.9-14.4 months) since ECMO cannulation, survival was 86.7%, including 1 patient who underwent lung transplantation. Of the patients discharged from the hospital, 44.4% (12/27) had pulmonary function testing, with a median percent predicted forced expiratory volume of 100% (IQR, 91%-110%). For survivors, a 6-minute walk test was performed in 59.3% (16/27), with a median value of 350 m (IQR, 286-379 m). ConclusionsA well-defined patient selection and management strategy of VV-ECMO support in patients with severe COVID-19 resulted in exceptional survival to discharge that was sustained at 1-year after ECMO cannulation.

Association of COVID-19 with Intracranial Hemorrhage during Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: A 10-Year Retrospective Observational Study.

Extracorporeal membrane oxygenation (ECMO) is potentially lifesaving for patients with acute respiratory distress syndrome (ARDS) but may be accompanied by serious adverse events, including intracranial hemorrhage (ICRH). We hypothesized that ICRH occurs more frequently in patients with COVID-19 than in patients with ARDS of other etiologies. We performed a single-center retrospective analysis of adult patients treated with venovenous (vv-) ECMO for ARDS between January 2011 and April 2021. Patients were included if they had received a cranial computed tomography (cCT) scan during vv-ECMO support or within 72 h after ECMO removal. Cox regression analysis was used to identify factors associated with ICRH. During the study period, we identified 204 patients with vv-ECMO for ARDS, for whom a cCT scan was available. We observed ICRH in 35.4% (n = 17/48) of patients with COVID-19 and in 16.7% (n = 26/156) of patients with ARDS attributable to factors other than COVID-19. COVID-19 (HR: 2.945; 95%; CI: 1.079–8.038; p = 0.035) and carboxyhemoglobin (HR: 0.330; 95%; CI: 0.135–0.806; p = 0.015) were associated with ICRH during vv-ECMO. In patients receiving vv-ECMO, the incidence of ICRH is doubled in patients with COVID-19 compared to patients suffering from ARDS attributable to other causes. More studies on the association between COVID-19 and ICRH during vv-ECMO are urgently needed to identify risk patterns and targets for potential therapeutic interventions.

Mechanical circulatory support devices in geriatric patients: more than just age.

The use of mechanical circulatory support (MCS) devices, such as left ventricular assist device and extracorporeal membrane oxygenation in the elderly have been rapidly increasing in various clinical settings over the past two decades. This review briefly summarizes recent literature on the role and outcomes of such mechanical circulatory support devices use in the elderly. Elderly patients are receiving increasing number of LVADs with improved survival and quality-of-life outcomes, despite multiple comorbidities. ECMO is a viable option in elderly patients but they have a higher risk of mortality after both VA ECMO and VV ECMO support. However, comorbidities, clinical presentation and timing of ECMO initiation seems to have a greater impact on prognosis than for younger patients. MCS device use continue to rise in the elderly population. Meticulously selected elderly patients could be successfully supported with MCS devices with favorable outcomes and acceptable mortality and complication rate.