There are limited data on the use of extracorporeal membrane oxygenation (ECMO) for pregnant and peripartum women with COVID-19 associated acute respiratory distress syndrome (ARDS). Pregnant women may exhibit more severe infections with COVID-19, requiring intensive care. We supported nine pregnant or peripartum women with COVID-19 ARDS with ECMO, all surviving and suffering no major complications from ECMO. Our case series demonstrates high-maternal survival rates with ECMO support in the management of COVID-19 associated severe ARDS, highlighting that these pregnant and postpartum patients should be supported with ECMO during this pandemic.

Background-Despite advances in surgical and percutaneous coronary revascularization, ongoing ischemia that is not amenable to standard revascularization techniques is a major cause of morbidity and mortality. Hepatocyte Growth Factor (HGF) has potent angiogenic and anti-apoptotic activities, and this study evaluated the functional and biochemical effects of HGF gene transfer in a rat model of postinfarction heart failure. Methods and Results-Lewis rats underwent ligation of the left anterior descending coronary artery with direct intramyocardial injection of replication-deficient recombinant adenovirus encoding HGF (nϭ10) or empty null virus as control (nϭ9)

Background: Bleeding complications are common with extracorporeal membrane oxygenation (ECMO).We investigated whether a heparin monitoring protocol using activated partial thromboplastin time (aPTT) and thromboelastography (TEG) affected clinical outcomes. Methods: This retrospective chart review stratified cohorts by study interval: pre-protocol (January 2016-March 2017) or post-protocol (March 2017-December 2017. The protocol defined therapeutic anticoagulation as aPTT of 60-80 seconds and a TEG reaction (TEG-R) time of 2-4× baseline; pre-protocol management used aPTT alone. The primary endpoints were the rates of bleeding and thrombotic events (clinical/device thrombosis) as defined by Extracorporeal Life Support Organization (ELSO) guidelines.Secondary endpoints included time in therapeutic aPTT range, rate of physician compliance with the protocol, time to heparin initiation, intensive care unit length of stay, mortality, and antithrombin III (ATIII) supplementation.Results: The pre-protocol (n=72) and post-protocol (n=51) groups (age 60±12 years; 80% on venoarterial ECMO; average ECMO duration of 6 days) showed no difference in baseline characteristics. Major bleeding events occurred in 69% of pre-protocol patients, versus 67% of post-protocol patients (P=0.85). The post-protocol group had fewer retroperitoneal bleeds (P=0.01) and had a non-significantly lower rate of pulmonary or central nervous system (CNS) bleeding (P=0.07). Thrombotic events occurred in 21% of the pre-protocol group, versus 28% of the post-protocol group (P=0.39). Mortality during ECMO support was significantly lower in the post-protocol group (56.9% vs. 33.3%, P=0.01). The thrombosis rate was higher in patients who received ATIII than in those who did not (48.2% vs. 15.9%, P<0.01). Conclusions: Major bleeding did not differ between the treatment groups. However, we observed significantly less mortality and retroperitoneal bleeding in the post-protocol group, suggesting an important gain from the intervention. Further study of the value of ATIII supplementation in ECMO patients is needed since we observed that a lower baseline ATIII level may indicate higher risk for thrombosis.

In this review, we discuss common difficulties that clinicians may encounter while managing patients treated with venovenous (VV) extracorporeal membrane oxygenation (ECMO). ECMO is an increasingly important tool for managing severe respiratory failure that is refractory to conventional therapies. Its overall goal is to manage respiratory failure-induced hypoxemia and hypercarbia to allow "lung rest" and promote recovery. Typically, by the time VV-ECMO is initiated, the patient's pulmonary condition requires conventional ventilator settings that are detrimental to lung recovery or that exceed the remaining functional lung's ability to maintain acceptable physiological conditions. Standard mechanical ventilation can activate inflammation and worsen the pulmonary damage caused by the underlying disease, leading to ventilator-induced lung injury. In contrast, VV-ECMO facilitates lung-protective ventilation, decreasing further ventilator-induced lung injury and allowing lung recovery. Such lung-protective ventilation seeks to avoid barotrauma (by monitoring transpulmonary pressure), volutrauma (by reducing excessive tidal volume to promote lung rest), atelectotrauma [by maintaining adequate positive end-expiratory pressure (PEEP)], and oxygen toxicity (by decreasing ventilator oxygen levels when PEEP is adequate). ECMO for adult respiratory failure was associated with overall survival of 62% in 2018, according to the Extracorporeal Life Support Organization (ELSO) January 2019 registry report. Difficulties that may arise during VV-ECMO require timely diagnosis and optimal management to achieve the most favorable outcomes. These difficulties include ventilation issues, hypoxemia (especially as related to recirculation or low ECMO-flowto-cardiac-output ratio), sepsis, malfunctioning critical circuit components, lack of clarity regarding optimal hemoglobin levels, hematological/anticoagulation complications, and right ventricular (RV) dysfunction. A culture of safety should be emphasized to optimize patient outcomes. A properly functioning team-not only the bedside clinician, but also nurses, perfusionists, respiratory therapists, physical therapists, pharmacists, nutritionists, and other medical specialists and allied health personnel-is vital for therapeutic success.