Comment
The use of ECMO has been advocated to sustain respiratory and/or
cardiovascular function and might represent the only effective
intervention in the difficult circumstances of circulatory instability
in COVID-positive cases (3). The COVID-BioB Study Group reported that
older age, cardiovascular disease, chronic lung disease, hypertension,
diabetes, and obesity are associated with worse outcomes (4). These risk
factors however were not present in our young patient who nevertheless
developed serious cardiovascular complications with pulmonary embolism,
embolic stroke, and right heart failure. Indeed, some patients with
COVID-19 infection will have a high incidence of venous and arterial
thromboembolism within an intensive care setting, which may lead to
fatal cardio-circulatory events (5). Interestingly, it was recently
reported that COVID-19 infection is associated with large-vessel stroke
in patients younger than 50 years (6) as observed in our patient, which
may be attributable to coagulopathy and vascular endothelial dysfunction
(7).
ECMO is traditionally utilized as rescue therapy in the most severe
cases of refractory cardiorespiratory failure. However, it is associated
with significant neurological, vascular, renal and hematological adverse
effects, including intra-cerebral hemorrhage, stroke, limb ischemia and
procoagulant states. As evidenced in this report, we successfully
employed various ECMO strategies, even in the challenging context of
contemporaneous acute ischemic stroke, which could risk hemorrhagic
conversion, central pulmonary embolism, kidney injury and upper limb
ischemia, following high-risk pulmonary endarterectomy in an unstable
patient. Thus, the judicious use of ECMO in carefully selected patient
cohorts in experienced centers may be of great benefit to, and achieve
favorable clinical outcomes in patients developing cardiorespiratory
complications during the current COVID-19 era. ECMO should be perceived
as an accessible and highly valuable tool in the clinician’s
armamentarium, rather than a “last resort” option in apparently futile
cases.
In conclusion, we report a successful outcome in a young patient who
underwent short-term MCS and high-risk cardiothoracic surgery for the
treatment of acute right heart failure with severe pulmonary embolism
and large-vessel embolic stroke as a complication of COVID-19 infection.
Short-term MCS with different cannulation strategies may represent a
viable treatment modality for cardiovascular complications with venous
and arterial thromboembolism in patients with COVID-19 infection.