key: cord-0878517-dvt86dz0 authors: Bhatia, Meena; Kumar, Priya A. title: Pro: Veno-arterial ECMO Should be Considered in Patients with COVID-19 date: 2020-11-18 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.11.027 sha: 17c0f45abe1d28fe2194fc13b538eeb3c124f2cd doc_id: 878517 cord_uid: dvt86dz0 nan patients with underlying cardiovascular disease (CVD) are at an increased risk of death. 2 In cases where the cardiovascular system is severely affected, the authors believe that veno-arterial extracorporeal membrane oxygenation (VA ECMO) should be considered for refractory cardiogenic shock. Our understanding of the mechanism by which SARS-CoV-2 affects cardiac function has only had a few months to grow, and to date remains incomplete. Data suggest that COVID-19 is associated with a severe systemic inflammatory response, resulting in a cytokine storm and the release of immune mediators. 3 Myocardial cells are at risk for direct injury from stress and increased oxygen demands in this environment. The renin-angiotensin aldosterone system (RAAS) mediates fundamental processes in human physiology. It encompasses a sequence of vasoactive peptides necessary for vasomotor tone, blood pressure and fluid regulation, as well as vascular homeostasis. 4 Angiotensin-converting enzyme 2 (ACE2) receptor is an enzyme that breaks down angiotensin II and counteracts harmful effects, such as hypertension, tissue injury and inflammation. Much like other coronaviruses, SARS-CoV-2 enters the body via these ACE2 receptors. These receptors are highly expressed on pulmonary alveolar cells but also exist, to a lesser Patients with these comorbidities were more likely to encounter severe disease and require intensive care treatment. Furthermore, the incidence of acute cardiac injury was at least thirteen times higher in patients with severe disease than those with non-severe disease. 9 non-survivors in this cohort, the incidence of heart failure increased to 52%. 11 In many of these studies, the affected patients were not offered VA ECMO or other advanced circulatory support therapies. The mortality in the cohort of COVID-19 patients with concomitant heart failure is high, and the long-term cardiovascular effects remain unknown. 12 The literature continues to report a significant proportion of patients suffering from cardiovascular complications, however, the role of VA ECMO and other circulatory support devices has yet to be established. It is well-known that patients suffering from cardiogenic shock carry a very high mortality without intervention. Mechanical circulatory support, specifically the use of VA ECMO, has become more widely utilized to help improve survival. Most studies quote 40-45% survival to hospital discharge after VA ECMO, however, it is important to note that pre-ECMO initiation risk factors such as younger age, lower weight, and reversible diagnoses such as acute myocarditis or arrhythmias, have better outcomes. 13 While most studies report 90 day survival as the benchmark, others show favorable long-term survival at up to three years post-discharge. 14 ECMO to provide them a fair chance for a full recovery. 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