Comment
The use of ECMO has been advocated to sustain respiratory and/or cardiovascular function and might represent the only effective intervention in the difficult circumstances of circulatory instability in COVID-positive cases (3). The COVID-BioB Study Group reported that older age, cardiovascular disease, chronic lung disease, hypertension, diabetes, and obesity are associated with worse outcomes (4). These risk factors however were not present in our young patient who nevertheless developed serious cardiovascular complications with pulmonary embolism, embolic stroke, and right heart failure. Indeed, some patients with COVID-19 infection will have a high incidence of venous and arterial thromboembolism within an intensive care setting, which may lead to fatal cardio-circulatory events (5). Interestingly, it was recently reported that COVID-19 infection is associated with large-vessel stroke in patients younger than 50 years (6) as observed in our patient, which may be attributable to coagulopathy and vascular endothelial dysfunction (7).
ECMO is traditionally utilized as rescue therapy in the most severe cases of refractory cardiorespiratory failure. However, it is associated with significant neurological, vascular, renal and hematological adverse effects, including intra-cerebral hemorrhage, stroke, limb ischemia and procoagulant states. As evidenced in this report, we successfully employed various ECMO strategies, even in the challenging context of contemporaneous acute ischemic stroke, which could risk hemorrhagic conversion, central pulmonary embolism, kidney injury and upper limb ischemia, following high-risk pulmonary endarterectomy in an unstable patient. Thus, the judicious use of ECMO in carefully selected patient cohorts in experienced centers may be of great benefit to, and achieve favorable clinical outcomes in patients developing cardiorespiratory complications during the current COVID-19 era. ECMO should be perceived as an accessible and highly valuable tool in the clinician’s armamentarium, rather than a “last resort” option in apparently futile cases.
In conclusion, we report a successful outcome in a young patient who underwent short-term MCS and high-risk cardiothoracic surgery for the treatment of acute right heart failure with severe pulmonary embolism and large-vessel embolic stroke as a complication of COVID-19 infection. Short-term MCS with different cannulation strategies may represent a viable treatment modality for cardiovascular complications with venous and arterial thromboembolism in patients with COVID-19 infection.