Extracorporeal Membrane Oxygenation Support for Antineutrophil Cytoplasmic Antibody-associated Vasculitides: An ELSO Registry Analysis

Abstract

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides with pulmonary involvement include granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, and can present with life-threatening pulmonary hemorrhage in up to 40% of patients. Mortality in those patients who require intubation and mechanical ventilation can reach 77%. Extracorporeal membrane oxygenation (ECMO) can be used to support these patients through definitive diagnosis and treatment, although minimizing the risk of ventilator-induced lung injury. We aimed to determine factors associated with favorable outcomes in patients with (ANCA)-associated vasculitides supported on ECMO. We performed a retrospective observational study using the Extracorporeal Life Support Organization registry of pediatric and adult patients with ANCA-associated vasculitis supported on ECMO from 2010 to 2020. One hundred thirty-five patients were included for analysis. Many patients had renal involvement (39%) in addition to pulmonary involvement (93%). Survival was 73% in AAV patients supported on ECMO. The presence of pulmonary hemorrhage was not associated with worse outcomes in our cohort. Older age, the use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, or sustaining a cardiac arrest before ECMO was associated with decreased survival. In conclusion, venovenous ECMO should be considered as a supportive bridge to definitive diagnosis and treatment in (ANCA)-associated vasculitides, regardless if pulmonary hemorrhage is present.

Venovenous Extracorporeal Membrane Oxygenation in Diffuse Alveolar Hemorrhage Secondary to Anti-neutrophil Cytoplasmic Autoantibody-associated Vasculitis: Starting without Systemic Anticoagulation

“…Supporting these patients with VV-ECMO ensures sufficient time to make a definite diagnostic and initiate treatment measures, along with minimizing ventilator-associated lung injury. The Extracorporeal Life Support Organization's registry of patients with AAV on ECMO showed a 73% survival rate, and factors associated with death included an older age, use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, and sustaining cardiac arrest before ECMO ( 3 ).…”

“…Several reports have described the benefits of performing venovenous-extracorporeal membrane oxygenation (VV-ECMO) for severe respiratory failure from DAH associated with AAV ( 3 , 4 ). During ECMO, patients receive anticoagulants that help prevent thrombotic complications and maintain circuit patency, placing them at the risk of bleeding ( 5 ).…”

Is Extracorporeal Membrane Oxygenation a Panacea?

“… 64 Veno-arterial ECMO is a suitable treatment option for poisoning cases complicated by refractory cardiogenic shock or cardiac arrest, offering high survival rates with low complications. 65 Extracorporeal membrane oxygenation may be indicated in severe status asthmaticus, 66 pheochromocytoma-induced cardiomyopathy, 67 , 68 fulminant myocarditis, 69 ANCA-associated vasculitis, 70 and refractory thyroid storm. 71 …”

Update on antineutrophil cytoplasmic autoantibody vasculitis in children

“…Children with DAH had higher mortality on ECMO (37%) than adults with DAH (17%). The authors concluded that venovenous ECMO should be used as needed [57].…”