Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry

Abstract

Background Multiple major health organisations recommend the use of extracorporeal membrane oxygenation (ECMO) support for COVID-19-related acute hypoxaemic respiratory failure. However, initial reports of ECMO use in patients with COVID-19 described very high mortality and there have been no large, international cohort studies of ECMO for COVID-19 reported to date. Methods We used data from the Extracorporeal Life Support Organization (ELSO) Registry to characterise the epidemiology, hospital course, and outcomes of patients aged 16 years or older with confirmed COVID-19 who had ECMO support initiated between Jan 16 and May 1, 2020, at 213 hospitals in 36 countries. The primary outcome was in-hospital death in a time-to-event analysis assessed at 90 days after ECMO initiation. We applied a multivariable Cox model to examine whether patient and hospital factors were associated with in-hospital mortality. Findings Data for 1035 patients with COVID-19 who received ECMO support were included in this study. Of these, 67 (6%) remained hospitalised, 311 (30%) were discharged home or to an acute rehabilitation centre, 101 (10%) were discharged to a long-term acute care centre or unspecified location, 176 (17%) were discharged to another hospital, and 380 (37%) died. The estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 37·4% (95% CI 34·4–40·4). Mortality was 39% (380 of 968) in patients with a final disposition of death or hospital discharge. The use of ECMO for circulatory support was independently associated with higher in-hospital mortality (hazard ratio 1·89, 95% CI 1·20–2·97). In the subset of patients with COVID-19 receiving respiratory (venovenous) ECMO and characterised as having acute respiratory distress syndrome, the estimated cumulative incidence of in-hospital mortality 90 days after the initiation of ECMO was 38·0% (95% CI 34·6–41·5). Interpretation In patients with COVID-19 who received ECMO, both estimated mortality 90 days after ECMO and mortality in those with a final disposition of death or discharge were less than 40%. These data from 213 hospitals worldwide provide a generalisable estimate of ECMO mortality in the setting of COVID-19. Funding None.

Current and evolving standards of care for patients with ARDS

“…All of these data suggest that vvECMO should be considered in patients still meeting EOLIA inclusion criteria, after less invasive therapies including prone positioning have been implemented or considered [88]. In other words, currently available data suggest that outcomes in ECMO are best when used in severe ARDS patients who are younger, with reversible etiology, few co-morbidities and when employed in experienced centers [89].…”

“…The role of vvECMO in the supportive care of patients with COVID-19 ARDS was initially questioned, but a recent analysis from the ELSO registry showed mortality of around 40% in these patients, similar to patients receiving vvECMO for other causes of ARDS and suggesting similar indications could be used [89].…”

Trend topics in prestigious and popular medical journals: The effect of Covid-19.

“…This resource brings together new 2019 novel coronavirus disease content from across The Lancet journals as it is published. One of the latest articles published online ahead of print in the journal is about extracorporeal membrane oxygenation support in Covid-19 [3].…”

What’s new in ECMO for COVID-19?

“…The largest report to date from the Extracorporeal Life Support Organization (ELSO) registry included patients from 213 centres across 36 countries [9]. Data on 1035 patients with COVID-19 supported with ECMO showed an estimated cumulative incidence of in-hospital mortality 90 days after ECMO initiation of 37% (95% CI 34-40).…”

“…There is greater uncertainty about the role of ECMO in other populations with COVID-19, such as patients requiring mechanical circulatory support, extracorporeal cardiopulmonary resuscitation (ECPR) [14], or those with multisystem inflammatory syndrome in children. Nonetheless, preliminary data appear to support the use of ECMO in many of these conditions as well [9,15]. The initial concerns that ECMO for COVID-19 was associated with unacceptable short-term outcomes have been assuaged, at least when ECMO is used in experienced centres.…”