COVID-19, ECMO, Surgical Applications
COVID-19 Cardiovascular Manifestations: Considerations for MCS
Several physicians discuss the cardiovascular manifestations of COVID-19 and the use of mechanical support in these patients with cardiac collapse with Daniel H. Raess, MD, and Tom Vassiliades, MD, in this open exchange of information call. We hear from Mark Anderson, MD, (Hackensack University Medical Center, New Jersey), David Schibilsky, MD (University of Freiburg, Germany), Duc Thinh Pham, MD (Northwestern University, Chicago), and Danny Ramzy, MD, (Cedars-Sinai Medical Center, Los Angeles).
Dr. Raess sets the framework for the discussion by reviewing the 3-phases of the progression of COVID-19.
COVID-19 Presentation of Disease Progression
|Phase I||Asymptomatic or mildy symptomatic phase||Days 1-5|
|Phase II||Pulmonary phase which intubation or V-V ECMO may be required||Days 2-5|
Host response phase:
May occur as patient is about to leave the ICU
Dr. Raess emphasizes that cardiac manifestations of SARS-CoV-2 infection are to be expected. COVID-19 can produce myocarditis-like effects as well as a toxic cytokine storm resulting in a procoagulant environment that can destabilize vulnerable plaques, resulting in ACS. Results from a study of patients with COVID-19 in Wuhan, China published in JAMA Cardiology on March 27, 2020, revealed that about 20% of patients had documented cardiac damage, and if they had elevated troponin levels, mortality in those patients was about 50%.
“We are seeing a lot of use of V-V ECMO,” Dr. Raess explains, “generally used early if proning fails to improve oxygenation… We are seeing cases with V-V ECMO and Impella®, and also some cases with V-A-V ECMO and Impella.” Dr. Raess shares information from Federico Pappalardo, MD, in Milan, Italy noting that Impella support—univentricular left ventricular support with Impella CP® or Impella 5.0®, biventricular support, or support in combination with ECMO (ECpella™)—has the potential to effectively tackle the hemodynamic features of COVID-19. Dr. Pappalardo also emphasizes the importance of paying attention not only to respiratory symptoms in patients with COVID-19, but also cardiac failure (myocarditis, hypoxic/septic dysfunction, heart disease decompensation).
Dr. Ramzy, in Los Angeles, reinforces the need to be aware of the cardiovascular manifestations of COVID-19. “I think it’s really a time to not only watch for the lungs, but watch for this cardiac decompensation, and be ready for it … Everyone who’s not ready should really be ready… It really creeps up very fast,” Ramzy emphasizes.
Dr. Anderson, located just outside Manhattan in Hackensack, New Jersey, echoes these sentiments. “The lesson that we’re learning here, is really that we have to heighten the awareness to the cardiovascular complications of this and disseminate that through the hospital to the residents that are literally alone managing these units, as well as the medical people in the ER and elsewhere.” Anderson emphasizes the importance of broadening the “tunnel vision” that COVID-19 has only a pulmonary component to encompass the broader perspective that patients may need different support, such as V-V ECMO.
Dr. Schibilsky in Germany notes that ECMO experience varies around the world. He reports that colleagues in Italy reported only a handful of patients on ECMO and none survived; while colleagues in Paris reported 80 patients on ECMO with good results and expected survival of over 50% in V-V ECMO patients.
Dr. Pham, in Chicago, emphasized the importance of daily COVID ICU conference calls at his institution. “Every morning we have a COVID ICU conference call with MICU [medical intensive care unit] team, thoracic surgeons who do most of the V-V ECMO, and heart failure group, cardiac surgery group, and cardiac anesthesia group.” He explains that this provides the hospital with the opportunity to look at ICU census, review patients, and identify patients possibly in need of mechanical support, such as V-V ECMO.
With regard to managing patients with proning, Dr. Pham reports, “We’ve had pretty good success with the proning here, and I’d say 80% of them have avoided needing escalation to anything else.” Dr. Anderson concurs. “We have found, like most people, that the proning has really been remarkably effective for these patients.”
When asked about the nature of their current situations, Dr. Anderson, whose institution was nearing the peak of the pandemic in the New York area, reports, “Currently we have maxed out. We used up all our ventilators a couple days ago…we’re approaching nearly 100 ventilated patients at this time, and, in excess of 300 in total in the hospital. So, it’s shut down everything. We’ve opened all the new units and ICUs. Using the outpatient building and tents outside… We’ve repurposed all the staff. Cardiac surgery is covering units.”
Regarding PPE, Dr. Pham reports that it has been difficult. “At this point, everyone in the COVID ICU gets their full PPE, but,… it’s nowhere near the level of protection we see internationally. Basically, what we have are modified N95 masks, head covers, impervious gowns and booties, and gloves. But not the full-on suits I’ve seen in other countries.”
In the midst of this COVID-19 pandemic, remember that the Clinical Support Center (CSC)—
1-800-422-8666—is staffed 24/7/365 and the Impella Connect® system allows completely HIPAA compliant data streaming from the AIC console to Abiomed so CSC staff can see what the nurse at the bedside is seeing on the console, allowing for unparalleled consultation in real time.