key: cord-0906107-878lelx4
authors: Kopanczyk, Rafal; Al-Qudsi, Omar H.; Uribe, Alberto; Periel, Luis; Fiorda, Juan; Abdel-Rasoul, Mahmoud; Kumar, Nicolas; Bhatt, Amar M.
title: Right Ventricular Dysfunction in Patients with Coronavirus Disease 2019 Supported with Extracorporeal Membrane Oxygenation
date: 2021-05-18
journal: J Cardiothorac Vasc Anesth
DOI: 10.1053/j.jvca.2021.05.019
sha: 1364eabf41c0ed9930fef2c81d73a0bfedf4f601
doc_id: 906107
cord_uid: 878lelx4

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dilation and RVD in 40% and 27%, respectively, the prevalence and severity of RVD in patients with COVID-19 requiring ECMO therapy is unknown. 4 Given this knowledge gap, we performed a pilot study evaluating RV function in patients with severe ARDS due to COVID-19 supported with conventionally cannulated, femoro-femoral VV ECMO.

Following Institutional Review Board approval, we analyzed point-of-care (POC) echocardiographic data acquired from adult COVID-19 patients on ECMO during clinical care in the cardiovascular intensive care unit between April 2020 to October 2020. A POC examination was triggered by hemodynamic instability and/or refractory hypoxemia. Two-dimensional (2-D) exams were performed in accordance with American Society of Echocardiography guidelines. 5 Tricuspid annular plane systolic excursion (TAPSE), tricuspid lateral annular systolic velocity (S'), and end-diastolic diameter (EDD) measurements were obtained. Images with frame rates >30 frames/sec were A total of 11 consecutive patients treated between April and October 2020 were analyzed. Table 1 presents demographic and clinical variables, and Table 2 presents the echocardiographic findings. The mean (SD) time to initial evaluation occurred at 9.17 RVD is a well-described complication of ARDS, with incidence varying between 22-50%. 6 Current evidence suggests similar rates in COVID-19 ARDS. 4 Patients with ARDS requiring VV-ECMO do not appear immune to this complication, with prepandemic studies reporting RVD in 18%-34% in this cohort. 1, 2 Our data further shows that a substantial number of patients with severe ARDS due to COVID-19 may develop clinically significant RVD while being supported with femoro-femoral VV ECMO. RV enlargement, abnormal myocardial free wall strain, and abnormal fractional area change were found in the majority of patients. Additionally, just under half of our patients experienced clinically significant RVD, defined as hemodynamic instability with echocardiographic stigmata of RVD and negative workup for other etiologies. While an improvement in RV function has been previously noted 3 following the initiation of VV ECMO, our findings suggest this effect may be short-lived. On average, RVD was found nine days into ECMO therapy.

Based on our results, RVD complicating ECMO support in patients with COVID-19 ARDS may be more ubiquitous than previously observed in other ARDS ECMO cohorts. Unique COVID-19 characteristics may be responsible for these findings.

Pulmonary microthrombi, endothelial injury, lung consolidation, iatrogenic therapies, and patient-specific characteristics such as obesity are just some factors that may play a role in RVD development. 7 Our findings have very important implications for patient care. Some centers around the U.S. pre-emptively changed their ECMO cannulation practices during the pandemic to promote RV protection with encouraging results. 8, 9 Our results provide additional data potentially supporting the use of dual staged cannulas in this population. 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. 

Right Ventricular Dysfunction and Mortality After Cannulation for Venovenous Extracorporeal Membrane Oxygenation

Assessment of Right Ventricular Function With CT and Echocardiography in Patients With Severe Acute Respiratory Distress Syndrome on Extracorporeal Membrane Oxygenation

Right ventricular unloading after initiation of venovenous extracorporeal membrane oxygenation. American journal of respiratory and critical care medicine

Spectrum of cardiac manifestations in COVID-19: a systematic echocardiographic study

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging

The right ventricle in ARDS

Extracorporeal Membrane Oxygenation and Coronavirus Disease

Extracorporeal Membrane Oxygenation with

Right Ventricular Assist Device for COVID-19 ARDS

Extracorporeal membrane oxygenation for patients with COVID-19 in severe respiratory failure