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Journal Pre-proof

Survival Benefits of Extracorporeal Membrane Oxygenation for Selected Patients

With Severe COVID-19

Michael Dandel, MD, PhD

PII: S0003-4975(22)00543-4
DOI: https://doi.org/10.1016/j.athoracsur.2022.04.012
Reference: ATS 36212

To appear in: The Annals of Thoracic Surgery

Received Date: 31 March 2022

Revised Date: 6 April 2022
Accepted Date: 6 April 2022

Please cite this article as: Dandel M, Survival Benefits of Extracorporeal Membrane Oxygenation
for Selected Patients With Severe COVID-19, The Annals of Thoracic Surgery (2022), doi: https://
doi.org/10.1016/j.athoracsur.2022.04.012.

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition
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© 2022 by The Society of Thoracic Surgeons

Survival Benefits of Extracorporeal Membrane Oxygenation for Selected Patients With
Severe COVID-19

To the Editor:

COVID-19 is associated with particularly frequent respiratory distress syndrome (ARDS)

which is also associated with higher mortality. The poorer prognosis of COVID-19 ARDS

results mainly from widespread endothelial damages which promote thrombogenesis and impair

vasoregulation in small pulmonary vessels, resulting in severe ventilation-perfusion mismatch.1

Because, without the use of extracorporeal membrane oxygenation (ECMO), the mortality rate

of
with severe COVID-19 ARDS can reach 85%2, the excellent one-year outcomes with veno-

ro
venous (VV) ECMO reported by Smith and colleagues3 are very promising.

-p
Evaluating exclusively patients supported by VV-ECMO, Smith et al.3 proved convincingly the
re
feasibility and life-saving value of VV-ECMO in appropriately selected patients with COVID-19
P

ARDS. The particularly good results of the study clearly speak against the initial hesitation towards

the use of ECMO in the management of COVID-19 ARDS. It still remains the question about the
al

previously published discrepancies regarding the usefulness of VV-ECMO, which were quite dis-
n
ur

couraging because the survival outcomes were often lower than those expected for non-COVID
Jo

ARDS. A possible explanation for those discrepancies could be differences in the prevalence of

acute cardio-respiratory failure necessitating both extracorporeal gas exchange and temporary

mechanical circulatory support. In one study, veno-arterial (VA) or other ECMO configurations

were necessary in 138 (9%) of the ECMO-supported patients with COVID-19 ARDS.4 Thus, the

existence of COVID-19 ARDS associated with acute cardio-respiratory failure, necessitating

both respiratory and circulatory support, must also be considered.

As proved by Smith et al., patient selection for VV-ECMO is reliably practicable. However,

data about the selection of patients with severe COVID-19 ARDS who may necessitate another type

of ECMO support are quite insufficient. Given the high incidence of diffuse pulmonary thrombotic

microangiopathy with consequent afterload mismatch-induced right ventricular (RV) failure, careful
echocardiographic monitoring of the right-sided heart for timely detection of RV pressure over-

loading becomes indispensable in patients with COVID-19 ARDS.1 Echocardiography can help

optimizing the selection of ECMO candidates and decision-making about the most appropriate

mechanical support strategy (VV-ECMO, VA-ECMO, or VV-ECMO plus RV or left ventricle

temporary percutaneous mechanical support).

Michael Dandel, MD, PhD

Associate Professor of Medicine
German Centre for Cardiovascular Research

of
13347 Berlin, Germany
E-mail: mdandel@aol.com

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References

1. Dandel M. (2021) Pathophysiology of COVID-19-associated acute respiratory distress syndrome

Lancet Respir Med. Jan;9(1):e4.

2. Zhou F, Yu T, Du R. et al. (2020) Clinical course and risk factors for mortality of adult

inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.

Lancet. 395:1054–62

3. Smith DE, Chang HS, Geraci TC. et al. (2022) One-Year Outcomes with Venovenous

Extracorporeal Membrane Oxygenation Support for Severe COVID-19.

of
Ann Thorac Surg. doi:10.1016/j.athoracsur.2022.01.003.

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4. Lorusso R, Combes A, Lo Coco V. et al. (2021) ECMO for COVID-19 patients in Europe
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and Israel. Intensive Care Med. 47(3):344-348.
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