ECMO support for COVID-19: a balancing act
Authors: Yang Zhang, Bingyang Ji, Zhou Zhou
Journal: The Lancet (2021)

We read with great interest the analysis of data from the Extracorporeal Life Support Organization (ELSO)1Barbado RP MacLaren G Boonstra PS et al.Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization Registry.Lancet. 2020; 396: 1071-1078Summary Full Text Full Text PDF PubMed Scopus (617) Google Scholar Registry. It provides valuable data that support the use of extracorporeal membrane oxygenation (ECMO) for patients with COVID-19. However, it is widely acknowledged that many critically ill patients with COVID-19 present with coagulation abnormalities that include thrombotic microangiopathy and venous and arterial thromboembolic complications.2Levi M Thachil J Iba T Levy JH Coagulation abnormalities and thrombosis in patients with COVID-19.Lancet Haematol. 2020; 7: 438-440Summary Full Text Full Text PDF PubMed Scopus (1068) Google Scholar, 3Connors JM Levy JH COVID-19 and its implications for thrombosis and anticoagulation.Blood. 2020; 135: 2033-2040Crossref PubMed Scopus (155) Google Scholar Hence, anticoagulants have been used in these critically ill patients both therapeutically and prophylactically.4Susen S Tacquard CA Godon A et al.Prevention of thrombotic risk in hospitalized patients with COVID-19 and risk in hospitalized patients with COVID-19 and hemostasis monitoring.Crit Care. 2020; 24: 364Crossref PubMed Scopus (113) Google Scholar, 5Tang N Bai H Chen X Gong J Li D Sun Z Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy.J Thromb Haemost. 2020; 18: 1094-1099Crossref PubMed Scopus (2426) Google Scholar During ECMO support, continuous contact of circulating blood cells with the surface of the extracorporeal circuit leads to the hypercoagulable state. As a result, anticoagulant therapy is necessary. Although heparin dosage, monitoring assays, and target values selected by most centres are specified in the 2014 ELSO anticoagulation guideline, balancing thrombosis and haemostasis under the double hit of COVID-19 and ECMO is a big challenge for clinicians. For these reasons, it would have been valuable to record the types and dosages of anticoagulants, the anticoagulant monitoring methods, and the target values. The big data survey and the authoritative statistical analysis of the ELSO Registry data would make it clear whether patients with COVID-19 who receive ECMO require higher doses of heparin to increase clinical benefits and which monitoring method is most suitable. We declare no competing interests. ECMO support for COVID-19: a balancing act – Authors' replyWe thank Yang Zhang and colleagues for their thoughtful letter in response to our study of extracorporeal membrane oxygenation (ECMO) support for COVID-19 from the Extracorporeal Life Support Organization (ELSO) Registry.1 They raise difficult questions concerning bleeding, thrombosis, and the use of anticoagulation in patients with COVID-19 receiving ECMO support. Full-Text PDF Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registryIn patients with COVID-19 who received ECMO, both estimated mortality 90 days after ECMO and mortality in those with a final disposition of death or discharge were less than 40%. These data from 213 hospitals worldwide provide a generalisable estimate of ECMO mortality in the setting of COVID-19. Full-Text PDF