What Does Survival Look Like After ECMO for COVID-19?

Registry data reaffirmed extracorporeal membrane oxygenation (ECMO) as a reasonable strategy for COVID-19 patients with severe respiratory problems, with most survivors discharged home and several going on to receive lung transplants.

Survival outcomes were outlined for 189 consecutive COVID-19 patients who had received ECMO support at 20 institutions at the time of the analysis:

• 98 died on ECMO or within 24 hours of decannulation
• 12 survived their ECMO run but died more than a day later in the hospital
• Nine are alive and remain in the hospital
• 70 were discharged alive from the hospital

“Our experience and analysis of 189 consecutive patients at 20 hospitals reveal that ECMO facilitates salvage and survival of select critically ill patients with COVID-19,” stated Jeffrey Jacobs, MD, of University of Florida in Gainesville, during the Society of Thoracic Surgeons (STS) virtual meeting.

The question now is how survivors fare over time.

By now, the ECMO registry includes more than 200 COVID-19 patients. Survivors are mostly discharged to their own homes, and four have received lung transplantation, Jacobs noted.

“Expansion of studies such as the current analysis presented here will provide a means to further define the role of ECMO in the management of severely compromised patients with COVID-19 and will serve to refine the optimal use of ECMO in these patients, with the goal of continuing to enhance survival,” he said.

Based on the experience of the 20 ECMO centers, those who were alive at last follow-up were significantly younger than non-survivors (average 46 vs 52.9, P<0.001).

Session co-moderator Errol Bush, MD, of Johns Hopkins in Baltimore, asked whether an age cutoff is appropriate for COVID-19 patients who are candidates for ECMO therapy.

“I don’t think any institutions have a specific age cutoff, because even though generally the younger patients tend to have better survival, in reality there’s plenty of older patients who are saved,” Jacobs said. “Age may guide expectations and counseling for families, but I don’t think these results have led anybody to a hard, firm cutoff.”

Jacobs added that the survivor group trended toward having more women (38.0% vs 26.4%) and people with fewer chronic conditions before SARS-CoV-2 infection (e.g., cancer, diabetes, heart disease), though these associations did not reach statistical significance.

The 189 people included in the study averaged age 50 and more two-thirds were men.

A notable difference between survivors and non-survivors was time spent from COVID diagnosis to intubation (mean 5.1 vs 8.7 days, P=0.008).

This supports anecdotal reports “that prolonged non-invasive ventilation appears to be associated with worse outcomes for those patients that transition to ECMO support,” commented Ryan Barbaro, MD, of University of Michigan in Ann Arbor.

Otherwise, the two groups shared similar numbers of days from intubation to cannulation (mean 4.2 vs 5.0 days), days on ECMO (20 days for both), and use of adjunctive therapies such as antiviral medication, convalescent plasma, and steroids.

The vast majority of people had been placed on veno-venous ECMO, which was associated with 43% survival versus 25% with veno-arterial ECMO.

Overall, Jacobs’ report echos the larger ELSO registry study that was released in September 2020.

“For example, the age, gender and comorbidities of patients were similar. There were also similarities in the care delivery practices. For instance, the days from intubation to ECMO start and the duration of ECMO support were similar. Finally, the survival to discharge from an ECMO hospital is also comparable between the two studies,” said Barbaro, who was the lead author of that paper.

“These study findings support major health organizations recommendation that it is appropriate for experienced ECMO centers to consider respiratory ECMO support in patients with COVID-19 who fail lung protective ventilation strategies,” he concluded.

Jacobs noted that his group is preparing a separate analysis of ECMO outcomes according to other variables such as acute kidney injury, pandemic surge stage, and center volume.