Introduction. Evidence regarding the impact of prophylactic implantation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for elective high-risk percutaneous coronary intervention (PCI) ...is limited. The purpose of this paper is to evaluate the outcome during index hospitalization and 3 years after interventions. Methods. This is an observational retrospective study including all patients undergoing elective, high-risk PCI and receiving VA-ECMO for cardiopulmonary support. Primary endpoints were in-hospital and 3- year major adverse cardiovascular and cerebrovascular event (MACCE) rates. Secondary endpoints were vascular complications, bleeding, and procedural success. Results. Nine patients were included in total. All patients were considered inoperable by the local heart team, and 1 patient had a previous coronary artery bypass graft (CABG). All patients were hospitalized for an acute heart failure episode 30 days before the index procedure. Severe left ventricular dysfunction was present in 8 patients. The main target vessel was the left main coronary artery in 5 cases. Complex PCI techniques were used: bifurcations with 2 stents in 8 patients, rotational atherectomy was performed in 3, and coronary lithoplasty in 1 case. PCI was successful in all of the patients with revascularization of all target and additional lesions. Eight of the 9 patients survived for at least 30 days after the procedure, and 7 patients survived for 3 years after the procedure. Regarding the complication rate, 2 patients suffered from limb ischemia and were treated by an antegrade perfusion, 1 patient had a femoral perforation that needed surgical repair, 6 patients had a hematoma, 5 patients had a significant drop in hemoglobin of more than 2 g/dl and received blood transfusions, 2 patients were treated for septicemia, and 2 patients needed hemodialysis. Conclusions. Prophylactic use of VA-ECMO in elective patients is an acceptable strategy for revascularization by high-risk coronary percutaneous interventions with good long-term outcomes for patients considered inoperable when a clear clinical benefit is expected. Regarding the potential risk of complications due to a VA-ECMO system, the selection of candidates in our series was based on a multiparameter analysis. The two main triggers in favor of prophylactic VA-ECMO in our studies were the presence of a recent heart failure episode and the high probability of periprocedural prolonged impairment of the coronary flow through the major epicardial artery.
Despite evidence suggesting a higher risk of barotrauma during COVID-19-related acute respiratory distress syndrome (ARDS) compared to ARDS due to other causes, data are limited about possible ...associations with patient characteristics, ventilation strategy, and survival.
This prospective observational multicenter study included consecutive patients with moderate-to-severe COVID-19 ARDS requiring invasive mechanical ventilation and managed at any of 12 centers in France and Belgium between March and December 2020. The primary objective was to determine whether barotrauma was associated with ICU mortality (censored on day 90), and the secondary objective was to identify factors associated with barotrauma.
Of 586 patients, 48 (8.2%) experienced barotrauma, including 35 with pneumothorax, 23 with pneumomediastinum, 1 with pneumoperitoneum, and 6 with subcutaneous emphysema. Median time from mechanical ventilation initiation to barotrauma detection was 3 0-17 days. All patients received protective ventilation and nearly half (23/48) were in volume-controlled mode. Barotrauma was associated with higher hospital mortality (P < 0.001) even after adjustment on age, sex, comorbidities, PaO
/FiO
at intubation, plateau pressure at intubation, and center (P < 0.05). The group with barotrauma had a lower mean body mass index (28.6 ± 5.8 vs. 30.3 ± 5.9, P = 0.03) and a higher proportion of patients given corticosteroids (87.5% vs. 63.4%, P = 0.001).
Barotrauma during mechanical ventilation for COVID-19 ARDS was associated with higher hospital mortality.
Different phenotypes have been identified in acute respiratory distress syndrome (ARDS). Existence of several phenotypes in coronavirus disease (COVID-19) related acute respiratory distress syndrome ...is unknown. We sought to identify different phenotypes of patients with moderate to severe ARDS related to COVID-19.
We conducted an observational study of 416 COVID-19 patients with moderate to severe ARDS at 21 intensive care units in Belgium and France. The primary outcome was day-28 ventilatory free days. Secondary outcomes were mortality on day 28, acute kidney injury, acute cardiac injury, pulmonary embolism, and deep venous thrombosis. Multiple factor analysis and hierarchical classification on principal components were performed to distinguish different clinical phenotypes.
We identified three different phenotypes in 150, 176, and 90 patients, respectively. Phenotype 3 was characterized by short evolution, severe hypoxemia, and old comorbid patients. Phenotype 1 was mainly characterized by the absence of comorbidities, relatively high compliance, and long duration of symptoms, whereas phenotype 2 was characterized female sex, and the presence of mild comorbidities such as uncomplicated diabetes or chronic hypertension. The compliance in phenotype 2 was lower than that in phenotype 1, with higher plateau and driving pressure. Phenotype 3 was associated with higher mortality compared to phenotypes 1 and 2.
In COVID-19 patients with moderate to severe ARDS, we identified three clinical phenotypes. One of these included older people with comorbidities who had a fulminant course of disease with poor prognosis. Requirement of different treatments and ventilatory strategies for each phenotype needs further investigation.
OBJECTIVES:
Venovenous extracorporeal membrane oxygenation has been largely used in patients with refractory acute respiratory distress syndrome due to coronavirus disease 2019. Few data on long-term ...pulmonary function among venovenous extracorporeal membrane oxygenation survivors are available.
DESIGN:
Retrospective, observational cohort.
SETTING:
Two mixed medical-surgical tertiary (30 beds) and secondary (22 beds) ICUs.
PATIENTS:
All critically ill adult coronavirus disease 2019 survivors treated with venovenous extracorporeal membrane oxygenation between March 10, and April 30, 2020.
MEASUREMENTS AND MAIN RESULTS:
The last available lung function and 6-minute walking tests, performed after a median of 178 days (ranges, 72–232 d) from ICU admission, were analyzed. Among the 32 coronavirus disease 2019 patients treated by venovenous extracorporeal membrane oxygenation during the study period, 11 (34%; median age 56 yr; median duration of mechanical ventilation and extracorporeal membrane oxygenation therapy of 26 and 15 d, respectively) were successfully weaned and discharged home. Spirometry was performed in nine patients; the volumetric lung function was preserved, that is, median forced vital capacity was 83% of predicted value (51–99% of predicted value), and median forced expiratory volume in 1 second was 82% of predicted value (60–99% of predicted value). Also, the median residual volume and the lung capacity were 100% of predicted value (50–140% of predicted value) and 90% of predicted value (50–100% of predicted value); only the diffusion capacity of the lung for carbon monoxide and 6-minute walking test were decreased (58% of predicted value 37–95% of predicted value and 468 meters (365–625 meters), corresponding to 63–90% of predicted value, respectively).
CONCLUSIONS:
Among survivors from severe coronavirus disease 2019 pneumonia treated with venovenous extracorporeal membrane oxygenation, preserved long-term volumetric lung function with decreased diffusion capacity of lung carbon monoxide was observed.
Controversies exist on the nature of COVID-19 related acute respiratory distress syndrome (ARDS) in particular on the static compliance of the respiratory system (Crs). We aimed to analyze the ...association of Crs with outcome in COVID-19-associated ARDS, to ascertain its determinants and to describe its evolution at day-14.
In this observational multicenter cohort of patients with moderate to severe Covid-19 ARDS, Crs was measured at day-1 and day-14. Association between Crs or Crs/ideal body weight (IBW) and breathing without assistance at day-28 was analyzed with multivariable logistic regression. Determinants were ascertained by multivariable linear regression. Day-14 Crs was compared to day-1 Crs with paired t-test in patients still under controlled mechanical ventilation.
The mean Crs in 372 patients was 37.6 ± 13 mL/cmH
O, similar to as in ARDS of other causes. Multivariate linear regression identified chronic hypertension, low PaO
/FiO
ratio, low PEEP, and low tidal volume as associated with lower Crs/IBW. After adjustment on confounders, nor Crs OR 1.0 (CI 95% 0.98-1.02) neither Crs/IBW OR 0.63 (CI 95% 0.13-3.1) were associated with the chance of breathing without assistance at day-28 whereas plateau pressure was OR 0.93 (CI 95% 0.88-0.99). In a subset of 108 patients, day-14 Crs decreased compared to day-1 Crs (31.2 ± 14.4 mL/cmH
O vs 37.8 ± 11.4 mL/cmH
O, p < 0.001). The decrease in Crs was not associated with day-28 outcome.
In a large multicenter cohort of moderate to severe COVID-19 ARDS, mean Crs was decreased below 40 mL/cmH
O and was not associated with day-28 outcome. Crs decreased between day-1 and day-14 but the decrease was not associated with day-28 outcome.
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