Establishment and Management of Mechanical Circulatory Support During the COVID-19 Pandemic
Authors: Duc Thinh Pham, Hadi Toeg, Ruggero De Paulis, Pavan Atluri
Journal: Circulation (2020)

ith >3 million cases worldwide, the novel coronavirus disease 2019 (COVID-19) pandemic presents a public health crisis that challenges the availability of healthcare practitioners and resources.Most patients who have COVID-19 present with no or mild symptoms.However, of 44 672 confirmed and presumed (attributable to exposure) cases reported in China, 14% had severe illness, and 5% were in critical respiratory failure, shock, and multisystem organ failure. 1 Twenty percent of patients present with some degree of cardiac injury, manifested by ECG abnormalities, arrhythmias, elevated troponin levels, and cardiac dysfunction. 2Although the prognosis of these abnormalities in stable patients remains poorly understood, myocardial collapse occurs in a small subset of patients.Extracorporeal membrane oxygenation (ECMO) represents a treatment option for COVID-19-related respiratory, cardiac, or combined cardiopulmonary failure.Current knowledge on ECMO use in COVID-19 infection remains limited to small series and registry data.The Italian experience provides preliminary data of critically ill patients.The majority of hospitalized patients were admitted for hypoxemic respiratory failure with intubation rates varying by center (30% to 88%).The mortality rate in critically ill patients was 26% to 84%. 3,4There was a varied presentation of cardiac manifestations, similar to those described earlier, often presumed secondary to myocardial injury. 3A webinar of the Japanese experience with venovenous ECMO (VV-ECMO for isolated respiratory failure) in patients with CO-VID-19 (n=32) demonstrated a successful wean rate from ECMO (67%), with low mortality (2%), with the remaining patients still supported.Two patients required conversion to venoarterial ECMO (VA-ECMO) because of cardiac dysfunction.Similarly, an April 28, 2020 review of the Extra-corporeal Life Support Organization registry denoted 604 COVID-19-related patients supported with ECMO (67% North America, 26% Europe), of whom 92% were initiated as VV-ECMO, with the remainder supported on VA-ECMO platforms.To date, 24% had been successfully weaned, of whom 43% were discharged alive.First-line therapy for critically ill patients with COVID-19 remains supportive, including early intubation with ventilatory support, neuromuscular blockade, pulmonary vasodilators, and prone positioning. 3In cases with COVID-19-related myocardial injury, initial support also remains medical, with inotropic and vasoconstrictor therapy.However, for scenarios with refractory pulmonary and myocardial compromise, strong consideration of early mechanical circulatory support, mainly ECMO, is warranted.Patient selection, treatment algorithm, inflow/outflow configuration, resource allocation, and effectiveness of ECMO have yet to be fully defined in COVID-19.We propose the following algorithm: (1) VV-ECMO for isolated respiratory failure; (2) mechanical circulatory support (including VA-ECMO) for isolated cardiogenic shock; or (3) VA-ECMO for cardiorespiratory failure (Figure).