COVID-19 Related Respiratory and Cardiac Failure: Roles for Advanced Therapy
Keshava Rajagopal, MD, PhD, discusses the use of conventional management strategies and cardiopulmonary support strategies for COVID-19-related respiratory failure and cardiac failure. Dr. Rajagopal is a professor in the department of clinical sciences at the University of Houston College of Medicine and surgical director, mechanical circulatory support and thoracic organ transplantation at HCA Houston Healthcare.
Dr. Rajagopal explains that the vast majority of therapies employed to date in the COVID-19 pandemic have been described in uncontrolled studies and the data is difficult to interpret. He examines conventional management strategies for COVID-19-related respiratory failure, including pharmacologic as well as ventilatory strategies and when to escalate. Pharmacologic strategies include monitoring systemic arterial oxygen saturation and potentially considering hydroxychloroquine if patients are hypoxemic or enrolling patients in a remdesivir or other antiviral clinical trial. He states that the strategy of early transition to invasive or noninvasive mechanical ventilation when patients deteriorate is now in question.
“I think it’s fair to say,” Dr. Rajagopal explains, “that the respiratory failure that’s caused by COVID-19 is similar enough to ARDS, that standard ARDS criteria that we use from the ARDSNet trial and others, guide our current management, which is to say, minimization of volutrauma and barotrauma.” Dr. Rajagopal also mentions that proning seems to have particular benefits in COVID-19 and he therefore recommends early proning in patients who are invasively mechanically ventilated.
Once patients have failed invasive mechanical ventilation, Dr. Rajagopal explains that it is important to determine the best management strategy rapidly before they experience irreversible or severe lung damage or other end-organ dysfunction. “The vast majority of patients that are encountered with COVID-19 who have fulminant organ failure (heart or lung), the vast majority of them really do have isolated respiratory failure.” For most of these patients, he explains, a reasonable management strategy is V-V ECMO via peripheral cannulation.
Dr. Rajagopal notes that a subset of those patients failing invasive mechanical ventilation may have sustained sufficiently severe respiratory failure to develop acute cor pulmonale. In these patients, it may be beneficial to support the right ventricle and pulmonary circulation. “In these patients there are a few circulatory support strategies that are reasonable,” states Dr. Rajagopal, “including catheter-based right ventricular assist devices, such as the Impella RP®, or paracorporeal pumps with a single cannula, such as the Protek Duo®. And in some cases, veno-arterial ECMO [V-A ECMO] may be used as a form of right ventricular support.”
Dr. Rajagopal explains that biventricular or left ventricular failure may occur in an even smaller subset of these patients. He notes that most of these patients have been supported with V-A ECMO with or without a device, such as Impella, to unload the left ventricle if there is evidence or concern about left ventricular distention.
Protek Duo is a registered trademark of CardiacAssist, Inc.
Emergency Use Authorization
The Impella RP System is authorized to be used by healthcare providers (HCP) in the hospital setting for providing temporary right ventricular support for up to 14 days in critical care patients with a body surface area ≥1.5 m2, for the treatment of acute right heart failure or decompensation caused by complications related to Coronavirus Disease 2019 (COVID-19), including pulmonary embolism (PE). The Impella RP has been authorized only for the duration of the declaration that circumstances exist justifying the authorization of the emergency use of medical devices under section 564(b)(1) of the Act, 21 U.S.C. § 360bbb-3(b)(1), unless the authorization is terminated or revoked sooner.