Discussion
It is necessary to understand that though the majority of children are
not seriously affected, there may be a subset of group children where
the COVİD-19 can progress rapidly deteriorate the respiratory functions
(5). Our patient is the youngest patient ever reported with the
progression of SARS-CoV-2 to severe disease requiring ECMO support after
cardiac surgery. The respiratory deterioration of this case is important
for understanding SARS-CoV-2 disease in newborns undergoing cardiac
surgery. Our patient, who developed rapid respiratory disorder in the
early postoperative period, was required ECMO support within the next 24
hours despite lung protective ventilation and high PEEP theraphy.
Current evidence shows that excessive inflammation, oxidation and an
extreme immune reaction play a significant role in the pathogenesis of
COVID-19 (6). Direct myocardial damage via angiotensin-converting enzyme
2, viral pneumonia, acute respiratory distress syndrome (ARDS), acute
lung injury, hypoxia induced myocardial damage, CPB related systemic
inflammatory response syndrome, pulmonary hypertansion related to CHD
may subscribe to inflammation course (6). Moreover, these events cause a
cytokine storm and results in ARDS (6). The immunity of the patients has
a major influence on the COVID-19 seriousness, and those with low immune
function, such as neonates, may be more susceptible, especially after
CPB (6).
According to the Extracorporeal Life Support Organization (ELSO)
registry as of 5 December 2020, ECMO support was used in 3543 confirmed
SARS-CoV-2 patients and in hospital mortality was 45% (7). Thrombosis
and bleeding complications are well-known risks of ECMO support. Some
studies announced a 70% incidence of bleeding and a 37% incidence of
thrombosis complications in children supported by ECMO (8). But ECMO
experience and literature is restricted in the SARS-CoV-2 disease (9).
Kaushik et al. reported a 5-year-old male patient who underwent ECMO
support with carotid artery cannulation due to SARS-CoV-2 multisystem
inflamatory syndrome (9). Unfortunately, right anterior and middle
cerebral artery infarction occurred on ECMO day 6 and finally the
patient succumbed to. The cause of stroke, for in this case, may be
multifactorial such as SARS-CoV-2 associated thromboembolic
complications or carotid artery cannulation strategy. A single-center
reported a 5% incidence of acute ischemic stroke on 221 patients with
SARS-CoV-2, and in addition, the incidence of ECMO-associated stroke in
children is known to be between 5.6% and 7.8% (10,11).
In our case, ARDS findings started on the postoperative 3rd day and the
respiratory functions of the patient deteriorated rapidly. Considering
that thromboembolic complications associated with SARS-CoV-2 may
increase, veno arterial ECMO support was applied with central
cannulation. Maybe for this reason, we did not observe thromboembolic
neurological complications, which may give symptoms such as anisocoria
or decrease in NIRS values during a total of 17 days of ECMO support.
The results of ECMO support in ARDS due to Covid 19 are associated with
high mortality. Henry et al. reviewed 234 COVID-19-related ARDS patients
in China, 17 of whom (7.25%) received ECMO, with a mortaliy rate of
94.1% in ECMO patients compared to 70.9% in conventional patients
(12). In our opinion, in addition to having undergone cardiac surgery in
the neonatal period, high ECMO mortality rates in ARDS due to COVID-19
negatively affected survival in our patient.