To the Editor We read with interest the study by Mustafa et al1 describing the experience of venovenous extracorporeal membrane oxygenation (ECMO) for coronavirus disease 2019 (COVID-19)–induced acute respiratory distress syndrome (ARDS), published in JAMA Surgery.
This publication is one of the largest case series describing the experience of venovenous ECMO support for COVID-19–induced ARDS from the United States. Initial reports from China suggested a very high mortality (84%-100%) in patients with COVID-19 who received ECMO support. However, recent studies from Europe have estimated the mortality burden in patients with COVID-19 supported with ECMO to be around 30%,2 which is similar to what is described in studies of patients with ARDS supported with ECMO outside the pandemic. The study by Mustafa et al1 reported an impressive survival benefit with ECMO support, with only 6 deaths of 40 patients (15% mortality). We are curious to know the authors’ opinion on what may have contributed to this improvement when the entry criteria remain similar to those from experienced ECMO centers in France.2
Driving pressure has been suggested to influence mortality in patients with ARDS, and steroid (dexamethasone) use has been reported to improve mortality in critically ill patients with COVID-19.3 Would the authors provide details about the reduction in driving pressure after ECMO initiation and steroid administration in their study cohort? The choice of cannulation configuration of dual-stage right atrium–to–pulmonary artery cannula use for ECMO support is intriguing. The authors state that this technique was chosen because of problems encountered in their first case with femoral-internal jugular cannulation configuration. Would the authors provide details about the right ventricular function of the study patients before ECMO initiation? If most patients had right ventricular dysfunction, is it possible to hypothesize that the dual-lumen cannula technique from the right atrium to pulmonary artery, bypassing the right ventricle, led to favorable outcomes?
Despite use of large-bore dual-lumen cannulas and higher therapeutic anticoagulation targets, the authors did not report any bleeding or neurologic complications in their patients, defying contemporary evidence.2,4 The blood flow in dual-lumen cannulas is generated by high pressures, and the large-bore dual-lumen cannulas are associated with increased intracranial and insertion site bleeding.5 We would appreciate the authors’ insight into the lack of bleeding and hemorrhagic stroke complications in their study cohort.
Corresponding Author: Chakradhar Venkata, MD, 625 S New Ballas Rd, Ste 7020, St Louis, MO 63141 (chakradhar.venkata@mercy.net).
Published Online: January 27, 2021. doi:10.1001/jamasurg.2020.6637
Conflict of Interest Disclosures: None reported.
2.Schmidt
M, Hajage
D, Lebreton
G,
et al; Groupe de Recherche Clinique en REanimation et Soins intensifs du Patient en Insuffisance Respiratoire aiguE (GRC-RESPIRE) Sorbonne Université; Paris-Sorbonne ECMO-COVID investigators. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study.
Lancet Respir Med. 2020;8(11):1121-1131. doi:
10.1016/S2213-2600(20)30328-3PubMedGoogle ScholarCrossref 3.Horby
P, Lim
WS, Emberson
JR,
et al; RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with COVID-19: preliminary report.
N Engl J Med. Published online July 17, 2020. doi:
10.1101/2020.06.22.20137273PubMedGoogle Scholar 5.Wengenmayer
T, Muellenbach
RM, Taccone
FS,
et al. Extracorporeal membrane oxygenation for critically ill patients with COVID-19-related acute respiratory distress syndrome: worth the effort!
Am J Respir Crit Care Med. 2020;202(10):1477-1479. doi:
10.1164/rccm.202006-2505LEPubMedGoogle ScholarCrossref