Veno-arterial extracorporeal membrane oxygenation for circulatory failure in COVID-19 patients: insights from the ECMOSARS registry
Authors: Anselmi Amedeo , Mansour Alexandre , Para Marylou , Mongardon Nicolas , Porto Alizée , Guihaire Julien , Morgant Marie-Catherine , Pozzi Matteo , Cholley Bernard , Falcoz Pierre-Emmanuel , Gaudard Philippe , Lebreton Guillaume , Labaste François , Barbanti Claudio , Fouquet Olivier , Chocron Sidney , Mottard Nicolas , Esvan Maxime , Fougerou-Leurent Claire , Flecher Erwan , Vincentelli André , Nesseler Nicolas ,   ECMOSARS Investigators, Pierrot Marc , Flicoteaux Guillaume , Mauriat Philippe , Ouattara Alexandre , Roze Hadrien , Huet Olivier , Fischer Marc-Olivier , Alessandri Claire , Bellaïche Raphel , Constant Ophélie , De Roux Quentin , Ly André , Meffert Arnaud , Merle Jean-Claude , Picard Lucile , Skripkina Elena , Folliguet Thierry , Fiore Antonio , D'Ostrevy Nicolas , Morgan Marie-Catherine , Guinot Pierre-Grégoire , Nguyen Maxime , Gaide-Chevronnay Lucie , Terzi Nicolas , Colin Gwenhaël , Fabre Olivier , Astaneh Arash , Issard Justin , Fadel Elie , Fabre Dominique , Girault Antoine , Ion Iolande , Menager Jean Baptiste , Mitilian Delphine , Mercier Olaf , Stephan François , Thes Jacques , Jouan Jerôme , Duburcq Thibault , Loobuyck Valentin , Moussa Mouhammed , Mugnier Agnes , Rousse Natacha , Manganiello Sabrina , Desebbe Olivier , Fellahi Jean-Luc , Henaine Roland , Pozzi Matteo , Richard Jean-Christophe , Riad Zakaria , Guervilly Christophe , Hraiech Sami , Papazian Laurent , Castanier Matthias , Chanavaz Charles , Cadoz Cyril , Gette Sebastien , Louis Guillaume , Portocarrero Erick , Brini Kais , Bischoff Nicolas , Levy Bruno , Kimmoun Antoine , Mattei Mathieu , Perez Pierre , Bourdiol Alexandre , Hourmant Yannick , Mahé Pierre-Joachim , Rozec Bertrand , Vourc'h Mickaël , Aubert Stéphane , Bazalgette Florian , Roger Claire , Jaquet Pierre , Lortat-Jacob Brice , Mordant Pierre , Nataf Patrick , Patrier Juliette , Provenchere Sophie , Roué Morgan , Sonneville Romain , Tran-Dinh Alexy , Wicky Paul-Henri , Zreibi Charles Al , Guyonvarch Yannis , Hamada Sophie , Bertier Astrid , Harrois Anatole , Matiello Jordi , Kerforne Thomas , Lacroix Corentin , Brechot Nicolas , Combes Alain , Schmidt Matthieu , Chommeloux Juliette , Constantin Jean Michel , D'Alessandro Cosimo , Demondion Pierre , Demoule Alexandre , Dres Martin , Fadel Guillaume , Fartoukh Muriel , Hekimian Guillaume , Juvin Charles , Leprince Pascal , Levy David , Luyt Charles Edouard , De Chambrun Marc Pineton , Schoell Thibaut , Fillâtre Pierre , Massart Nicolas , Nicolas Roxane , Jonas Maud , Vidal Charles , Allou Nicolas , Muccio Salvatore , Di Perna Dario , Ruggieri Vito-Giovanni , Mourvillier Bruno , Bounader Karl , Launey Yoann , Lebouvier Thomas , Parasido Alessandro , Reizine Florian , Seguin Philippe , Besnier Emmanuel , Carpentier Dorothée , Clavier Thomas , Olland Anne , Villard Marion , Bounes Fanny , Minville Vincent , Guillon Antoine , Fedun Yannick , Ross James T 
Published: June 2023

Abstract

OBJECTIVES
The clinical profile and outcomes of patients with Coronavirus Disease 2019 (COVID-19) who require veno-arterial extracorporeal membrane oxygenation (VA-ECMO) or veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) are poorly understood. We aimed to describe the characteristics and outcomes of these patients and to identify predictors of both favourable and unfavourable outcomes.

METHODS
ECMOSARS is a multicentre, prospective, nationwide French registry enrolling patients who require veno-venous extracorporeal membrane oxygenation (ECMO)/VA-ECMO in the context of COVID-19 infection (652 patients at 41 centres). We focused on 47 patients supported with VA- or VAV-ECMO for refractory cardiogenic shock.

RESULTS
The median age was 49. Fourteen percent of patients had a prior diagnosis of heart failure. The most common aetiologies of cardiogenic shock were acute pulmonary embolism (30%), myocarditis (28%) and acute coronary syndrome (4%). Extracorporeal cardiopulmonary resuscitation (E-CPR) 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 1, 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 body mass index (P = 0.03), E-CPR (P = 0.001), non-myocarditis aetiology (P = 0.02), higher serum lactates (P = 0.004), epinephrine (but not noradrenaline) use before initiation of ECMO (P = 0.003), haemorrhagic complications (P = 0.001), greater transfusion requirements (P = 0.001) and more severe Survival after Veno-Arterial ECMO (SAVE) and Sonographic Assessment of Intravascular Fluid Estimate (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.