Shifting Paradigms in ECMO Support for Severe COVID-19 Respiratory Failure Result in over 80% Hospital Survival in 2021

PURPOSE: The role of ECMO support for COVID-19 patients with severe respiratory failure has evolved over the course of the pandemic. Rapid exchange of experience among caregivers led to changes in ECMO support strategies, and patient management that resulted in improved outcomes in recent pandemic waves. We present our 18 months experience comparing patient outcomes in 2020 vs 2021. METHODS: We present a single institution retrospective analysis of patients receiving ECMO for COVID-19 ARDS. Patient data include demographics, comorbidities, time from admission to intubation and to initiation of ECMO support, type and duration of ECMO support, major patient and ECMO circuit complications, and hospital survival to discharge, or acceptance/transfer to lung transplant center. RESULTS: A total of 20 patients were identified for analysis. The cohort was predominantly male (65%) with an age and body mass index (BMI) average of 49.2±10.2 years and 32.8±5.9 kg/m2, respectively The average length of stay was 44.8±16.3 days and 55%. Most common support mode was veno-venous ECMO (90%) with a right femoral vein/right internal jugular cannulation (60%), and 75% required ECMO-circuit exchange. Comparing patients supported in 2020 vs 2021, time from intubation-to-ECMO, admission-to-tracheostomy, and ECMO-to-discharge were statistically significant (p=0.015; 0.014; 0.05; CI 95%). Overall survival rate was 65%, with a significant increase to 83% in 2021. Congruently, 55% of all discharged patients underwent ambulatory physical therapy treatment. ECMO-related complications were observed in 30% of the patients, including cardiovascular accident (CVA) (20%), clotting of the system (15%), and hemorrhaging from tracheostomy requiring revision (20%). When comparing groups, early tracheostomy was related to improved survival (p=0.014, CI 95%). 35% patients were accepted / transferred for lung transplantation. CONCLUSION: Changes in management of patients receiving ECMO for COVID19 ARDS, including anticoagulation with bivalirudin, early tracheostomy and physical therapy, conversion to VAV ECMO, and referral to lung transplant resulted in 60 day hospital survival of 83% in 2021.