key: cord-0891551-fn30agno authors: Awad, Wael I.; Bashir, Mohamad title: Mechanical circulatory support—Challenges, strategies, and preparations date: 2021-01-13 journal: J Card Surg DOI: 10.1111/jocs.15301 sha: ca2c1496dfebe05158a37806d446c0536194a708 doc_id: 891551 cord_uid: fn30agno BACKGROUND: Coronavirus disease 2019 (COVID‐19) is usually mild, but patients can present with pneumonia, acute respiratory distress syndrome (ARDS), and circulatory shock. Although the symptoms of the disease are predominantly respiratory, the involvement of the cardiovascular system is common. Patients with heart failure (HF) are particularly vulnerable when suffering from COVID‐19. AIM OF THE REVIEW: To examine the challenges faced by healthcare organizations, and mechanical circulatory support management strategies available to patients with heart failure, during the COVID‐19 pandemic. RESULTS: Extracorporeal membrane oxygenation (ECMO) can be lifesaving in patients with severe forms of ARDS, or refractory cardio‐circulatory compromise. The Impella RP can provide right ventricular circulatory support for patients who develop right side ventricular failure or decompensation caused by COVID‐19 complications, including pulmonary embolus. HT are reserved for only those patients with a high short‐term mortality. LVAD as a bridge to transplant may be a viable strategy to get at‐risk patients home quickly. Elective LVAD implantations have been reduced and only patients classified as INTERMACS profile 1 and 2 are being considered for LVAD implantation. Delayed recognition of LVAD‐related complications, misdiagnosis of COVID‐19, and impaired social and psychological well‐being for patients and families may ensue. Remote patient care with virtual or telephone contacts is becoming the norm. CONCLUSIONS: HF incidence, prevalence, and undertreatment will grow as a result of new COVID‐19‐related heart disease. ECMO should be reserved for highly selected cases of COVID‐19 with a reasonable probability of recovery. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs. Coronavirus disease 2019 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease is usually mild, although occasionally severe with patients presenting with pneumonia, acute respiratory distress syndrome (ARDS), and circulatory shock (CS). 1 In a recent report, 26 .1% of 138 COVID-19 patients needed to be admitted to the intensive care unit (ICU), of which 61.1% were suffering from ARDS. The heterogeneity of responses between individual patients is marked indicating host characteristics promote progression of the disease with a range of different presentations from mild symptoms to multiorgan failure. Although the clinical symptoms of the disease are predominantly respiratory, direct and indirect involvement of other organs is common, with the cardiovascular (CV) system being particularly affected. Moreover, pre-existing conditions, largely linked to CV disease (CVD), increase the risk of severe outcomes of the infection. A large Chinese study analyzing data of 44,672 confirmed COVID-19 cases revealed 12.8% had hypertension, 5.3% diabetes, and 4.2% CVD. 2 A further study of 5700 patients from the United States reported a similar message that hypertension (56.6%), obesity (41.7%), diabetes (33.8%), CAD (11.1%), and congestive heart failure (6.9%) were common comorbidities in patients with COVID-19. 3 Older patients are more likely to experience ICU admission, mechanical ventilation, or death compared with younger patients, and males seem to be more susceptible to COVID-19-related complications. COVID-19 has resulted in substantial policy change and strain on existing healthcare infrastructure. Many healthcare providers have had to scale down outpatient services and defer elective cardiac procedures and operations with re-deployment of the workforce to help manage the pandemic. The long-term clinical impact of scaling down outpatient activity, reduced access to investigations, and cancellation of routine procedures will have consequences beyond the pandemic. In addition, the perceived risk of being exposed to COVID-19 has led to a delay in presentation of acute cardiac emergencies with a likelihood of increasing cardiac mortality and morbidity. Until now, no specific treatment has been recommended for COVID-19, although extracorporeal membrane oxygenation (ECMO), providing effective respiratory or cardiac support, can be regarded as a rescue therapy for severe ARDS. Patients with cardiovascular risk factors and established cardiovascular disease, including heart failure (HF), are particularly vulnerable when suffering from COVID-19 4,5 and patients with cardiac injury in the context of COVID-19 have an increased risk of morbidity and mortality. 6 Guzik et al. 7 report a mortality rate ∼0.9% for patients with no comorbidities and much higher for patients with comorbidities (10.5% for patients with CV disease, 7.3% for those with diabetes, 6% for those with hypertension and 6.3% for those with chronic respiratory disease. 8 -2 anchors on transmembrane ACE2 to enter the host cells including type 2 pneumocytes, macrophages, endothelial cells, pericytes, and cardiac myocytes, 9 leading to inflammation, severe microvascular 10 In patients with COVID-19 infection, hypoxemic respiratory failure, and ARDS can exacerbate pulmonary vasoconstriction and interstitial edema, worsening pulmonary hypertension even in patients without pre-existing lung disease. 16 In patients with preexisting biventricular failure, further elevation in pulmonary pressures secondary to ARDS can worsen right ventricular function. In a large cohort study of 138 patients, 8.7% of patients presented with shock, 7.2% with acute cardiac injury, and 16.7% with arrhythmias. 17 Various other reports show new-onset heart failure/ cardiomyopathy in up to one-third of critically ill patients admitted with COVID-19 infection. 18, 19 A special population at risk for COVID-19 includes patients supported with left ventricular assist devices (LVADs). These patients are chronically affected by long-standing cardiovascular diseases and are subjected to variations of the normal cardiovascular physiology due to a non-pulsatile blood flow, exposure of the blood to artificial surfaces, and risk of hemorrhagic and thrombotic events. Patients with advanced HF, including those with durable LVAD support, have severely reduced functional capacity, 20,21 as measured by peak VO 2 , and impaired ability to augment cardiac output in response to physiological stressors. These factors collectively decrease their cardiopulmonary reserve. Patients with COVID-19 infection are at higher risk for thrombosis in the arterial and venous circulations due to endothelial dysfunction, inflammation, oxidative stress, and platelet activation 22 ; both may trigger decompensation of pre-existing HF or development of de novo acute HF. Right ventricular failure can also develop secondary to elevated pulmonary pressures in the setting of ARDS and/or pulmonary embolism. 23 HF incidence, prevalence, and undertreatment will likely grow as a result of new COVID-19-related heart disease, delays in the recognition and treatment of ischemic heart disease, rising unemployment, and loss of income and health benefits for large segments of the population. Special considerations are needed for patients with advanced HF, including those supported by durable LVADs and heart transplantation (HT) recipients. Treatment options for COVID-19 myocarditis are still evolving. However, mechanical circulatory support devices and life support therapies such as veno-venous ECMO (VV-ECMO) and VA-ECMO may be beneficial in select cases. The mortality in COVID-19 patients who require mechanical ventilation is high. Extracorporeal membrane oxygenation can be lifesaving in patients with severe forms of ARDS, or refractory cardio-circulatory compromise. While accepting that resource scarcity may be the overwhelming concern for healthcare systems during this pandemic, VA-ECMO can be considered in highly selected cases of refractory CS and biventricular failure. The decision to initiate this therapy should take into consideration the availability of resources, perceived benefit, and risks of transmitting disease to patients and staff. The Extracorporeal Life Support Organization (ELSO) recommends consideration of VA-ECMO in refractory CS that persists despite adequate fluid resuscitation, inotropes, and vasopressor support. 24 Contraindications to VA-ECMO include advanced age, lifethreatening noncompliance, and significant medical comorbidities. 24 The Society of Critical Care Medicine guidelines for the management of COVID-19 patients recommends the use of ECMO when conventional management fails. 25 The provision of ECMO, also is dependent on local institution and regional policies. ECMO requires specialized equipment, training (of physicians, nursing staff, and perfusionists), and delivery of care in specialized critical care units. MacLaren et al. 28 suggest, resources may well be better concentrated to ensure that enough ICU beds, ventilators, and personal protective equipment are available to deal with the influx of patients encountered during the pandemic. Providing this level of care should be considered dynamically on a case-by-case basis as the local situation and resource availability changes (ie, critical care beds, healthcare personnel, equipment). Assessment provided with a virtual visit can also include evaluation of LVAD controller parameters and screening for adverse events, in addition to counseling. 34 Since prevention is currently the best strategy for COVID-19, home management requires that healthcare professionals innovate ways to follow LVAD patients virtually and advise them with instructions to self-quarantine, take hygiene actions and social distancing measures for prevention of disease and transmission. Healthcare professionals should limit all elective medical visits and testing, arrange for in-home blood-testing and home international normalized ratio monitoring as well as emphasize the importance of nutrition, sleep, and exercise. Patients' families and caregivers must also be protected and practice self-care measures for safety. Delivering optimal support to LVAD implanted patients during the COVID-19 pandemic include creating local support networks to deliver educational materials, extra pro-active phone calls from the VAD coordinator. Those with limited access to the internet and/or "smart" devices may not derive benefit from the expansion of these innovations. Older adults may have educational, visual, auditory, and cognitive impairments that hinder their participation in remote care. The option for in-person clinic visits should remain available for patients without access to telemedicine services, high-risk patients, or those for whom physical examination is critical for clinical decision making. Additionally, time should be spent for psychological support and reassurance. Optimal self-care includes behavior to maintain and increase psychological wellbeing to optimally cope with an LVAD. During the COVID-19 pandemic, patients have an increased level of anguish than the general population. 35 Patients worry about being infected and they worry about the wellbeing of their caregiver. They also worry about changes in their relationship with their close homebound caregiver on whom they become even more dependent. Psychological distress can be accelerated by the lack of physical activity, social deprivation, isolation, and loneliness. The use of established behavioral and social science approaches need to identify the active components of "psychological support" that are most applicable to each individual patient with a VAD. ECMO has, and will certainly continue, to play a role in the management of COVID-19 patients. It should be emphasized that this initial guidance is based on the current best evidence for ECMO use during this pandemic. 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