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Mechanical Circulatory Support in COVID-19: When to Consider, What to Expect?

Soltesz E, Surgical Director of Cleveland of the Kaufman Center for Heart Failure and Recovery, from a recent Tall Rounds online CME activity from Cleveland Clinic covering COVID-19 and the heart published online In Consult QD.

Link

 

 

Key Points:

This summary describes the uses and potential limitations of Extracorporeal membrane oxygenation (ECMO) as well as other mechanical Circulatory (MCS) Devices.

  • Circulatory support in COVID – 19 patients is likely most effective for single organ system disease such as acute respiratory distress syndrome (ARDS) and/or cardiogenic shock.
  • Limitations involve patients with cytokine-mediated myocardial dysfunction plus severe respiratory failure, who despite support have a limited prognosis.
  • VV-ECMO and ARDS. (Extracorporeal Life Support Organization – ELSO).
    • Notes:
  • Contraindications include: older age, mechanical ventilations >7days; multiorgan failure.
  • VV-ECMO Oxygen indications focus on the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2:FiO2)
  • VV ECMO indicated if PaO2:FiO2 ≥ 150 mmHg and
    • pH < 7.25 with PaCO2 ≥ 60 mmHg for > 6 hours.
  • For those with PaO2:FiO2 < 150 mmHg and
    • PaO2:FiO2 < 80 mmHg for > 6 hours  
    • PaO2:FiO2 < 50 mmHg for > 3 hours
    • pH < 7.25 with PaCO2 >60 mmHg for > 6 hours.
  • Challenges to VV-ECMO include:
    • Prolonged ECMO support requires – up to 3 weeks due to slow lung healing.
    • Systemic inflammation producing a prothrombotic state requiring large heparin and/or bivalirudin dosages.
    • Potential ECMO induced advancement of of COVID – 19 to other organ systems.
  • Hemodynamic Support for the Management of Cardiogenic Shock
    • Optimal for left ventricular failure from a viral myocarditis – as an isolated organ problem.
  • Goals of Support
    • To provide adequate tissue perfusion (To break the shock spiral)
    • Unload the injured ventricle serving as a bridge to recovery, transplant or a permanent device.
  • Potential Devices:
    • Veno-arterial ECMO (VA-ECMO)
  • Advantages – can be implanted at bedside and provides full, biventricular support
  • Disadvantages – Lack of ventricular unloading adversely effecting left ventricular recovery (LV) while increasing risk of lung injury, risk of aortic/LV thrombosis as well as hemolysis. Lastly, it is unable to uncouple the left and right ventricles challenging the ability to predict next requirements. Ambulation generally not possible.
    • Impella
  • Advantages – Completely unloads the LV, protecting the lungs. Long term support is possible beyond one month with the larger devices. In addition, it has a low rate of hemolysis Ambulation is feasible with axillary cannulation (often surgical).
  • Disadvantages – Surgical implantation requires surgery and transesophageal echocardiogram for placement which possibly increases increased risk to personnel.
    • Temporary right-ventricular assist devices (RVADs)
  • Device types – ProtekDuo/TandemHeart, CentriMag and Impella RP
  • An oxygenator can be spliced in to provide an oxy-RVAD configuration.
  • Specific management:
    • Combined devices – Frequently beneficial – VA ECMO with combined Impella for unloading.
    • Heart Team Decisions critical
  • Summary
    • In appropriately selected patients, particularly with COVID – 19, these devices can be lifesaving.

 

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In The News

The New Pandemic Threat: People May Die Because They’re Not Calling 911 There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.

Key Points:

  • There has been a dramatic decrease in Myocardial Infarction presentations worldwide during the current COVID – 19 Pandemic.
  • Multiple reasons for the reduction in infarctions have been postulated but a worrisome and likely significant one is that patients don’t seek care promptly, if at all for symptoms of a heart attack.
  • This “New Pandemic Treat” Statement is signed by multiple organizations and is directed to patients – emphasizing the importance of immediately seeking treatment for important heart attack and stroke symptoms.
  • Perhaps as physicians are communicating with patients remotely, healthcare professionals might consider downloading and distributing this statement to their patients to combat an important, “indirect” COVID – 19 risk!
  • Pass this statement on – its an inexpensive but important “Vaccine” – A 911 Call.
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In The News

CMS Recommendations Re-opening Facilities to Provide Non-emergent Non-COVID-19 Healthcare: Phase I

On April 17, CMS announced a plan to begin allowing the elective procedures resume. Below is a brief summary of the requirements.

  • States or Regions must meet “Gating Criteria”
    • A lowering trend in flu-like illnesses, COVID – 19 Cases/or positive test numbers percentages during a 14 day period.
    • An effective COVID – 19 testing program for potentially exposed healthcare workers.
  • Reopening Facilities will require.
    • Testing equipment.
    • Appropriate numbers of workforce for the care of patients.
    • Sufficient PPE.
    • Being prepared for a potential surge in COVID – 19 Cases.
  • Optimal strategy is to have hospitals establish COVID Free Units (“non-COVID Care (NCC) zones”)
    • Staff only work in these areas (No cross rounding between COVID – 19 Patients or units and NCC area.
    • Such units will require strict screening for patients before entry and for staff.
    • Screening emphasizes clinical assessment for recent symptoms and fever.
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Coagulopathy Associated with COVID-19

An international panel provides guidance on prognostic variables and management strategies for COVID-19–associated coagulopathy

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In The News

An Interview With an Italian Intensivist on the COVID Experience in Italy – American College of Cardiology

Key Points:

 

 

  • Reaffirms primary presentation is respiratory
  • Cardiovascular Involvement is definite; often myocarditis, but concerns of excluding traditional infarction induced by high inflammatory markers.
  • Use of Hemodynamic support is used selectively, often with V-V ECMO for oxygenation but other considerations include conversion to V-A ECMO with considerations for Impella unloading (ECPella)
  • Challenges in managing cardiogenic shock include limitation of Right Heart Catheterization and the challenges of potentially placing an Impella in the ICU. (See Posted article on A-Cure sight Pappalardo description of ICU Impella Insertion.)
  • Deciding on Resource utilization generally targets patients based on blood pressure levels, pressors required and Left Ventricular Ejection Fraction.
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In The News

A Heart Attack? No, It Was the Coronavirus.

New York Times 3/29/2020

Cardiologists are seeing infected patients whose worst symptoms are not respiratory, but cardiac.

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