We identified 33 patients that met the aforementioned inclusion criteria, Baseline demographic characteristics, as well as risk factors and comorbidities, are summarized in Table 1. The mean age was 49 ± 9 years. 73% (n = 24) of patients were male. The majority of our patients were non-white (79%, n = 26). This was a significant finding as the WWAMIO region is overwhelmingly populated by white Caucasians, indicating ethnic minorities are more severely affected by COVID-19.
Table 1
Patient related factors and comorbidities and the prevalence of right ventricular dysfunction.
Demographics and PMH
|
Total, n = 33
|
No RV Dysfunction, n = 19
|
RV Dysfunction, n = 14
|
P value
|
Mean Age (yrs) +/- STDV
|
48.7 +/- 9.2
|
50.4 +/- 7.7
|
46.5 +/- 10.5
|
|
Mean BMI +/- STDV
|
30.2 +/- 3.5
|
30.9 +/- 3.4
|
29.3 +/- 3.6
|
|
Male
|
72.7%
|
73.7%
|
71.4%
|
|
Non-White
|
78.8%
|
73.7%
|
85.7%
|
|
DM %
|
36.36%
|
42.11%
|
28.60%
|
0.109
|
HTN %
|
33.33%
|
42.11%
|
21.43%
|
0.0104
|
Smoker %
|
35.48%
|
29.41%
|
42.86%
|
0.109
|
Lung Disease (OSA, Asthma, COPD) %
|
27.27%
|
15.79%
|
42.86%
|
0.0002
|
Risk Factors For Right Ventricular Dysfunction
RV dysfunction was identified in 42% (n = 14). 24% (n = 8) never had echocardiographic studies. History of lung disease including obstructive sleep apnea, asthma, and COPD were 2.7 times more prevalent in the RV dysfunction group than the no RV dysfunction group (p = 0.00021). Of the RV dysfunction cohort, 3 received percutaneous RVAD support in the form of percutaneous dual lumen cannula through the right internal jugular vein inserted under fluoroscopic guidance.
Troponin and BNP were shown to be 6 times and 4 times higher in the RV dysfunction cohort, whereas AST and creatinine levels were not observed to be statistically different between the two groups (see Table 2).
Table 2
Surrogates for end organ dysfunction.
Surrogates for End Organ Dysfunction
|
Total, n = 33
|
No RV Dysfunction, n = 19
|
RV Dysfunction, n = 14
|
P Value
|
Mean Peak AST
|
539.2
|
583.2
|
479.6
|
0.841
|
Mean Peak Creatinine
|
2.3
|
2.2
|
2.5
|
0.710
|
Mean Peak BNP
|
433.3
|
158.5
|
662.3
|
0.037
|
Mean Peak Troponin I
|
0.24
|
0.07
|
0.44
|
0.039
|
Complications
We observed that 69% (n = 23) of our patients developed ventilator-associated pneumonia. Hemorrhagic complications took place in 51% (n = 17), followed by thromboembolic phenomenon in 30% (n = 10) urinary tract infections in 21% (n = 7), bacteremia in 21% (n = 7), pneumothorax in 15% (n = 5) and heparin-induced thrombocytopenia (HIT) in 15% (n = 5).
A more in-depth analysis revealed that RV dysfunction was associated with a two fold increased risk of pulmonary embolism (21.42% vs. 10.53%, p = 0.04) and two fold higher risk of thrombosis/deep venous thromboses (42.85% vs. 21.05%, p = 0.0046). Table 3 summarizes complication rates as related to RV dysfunction.
Table 3
Complication rates as related to presence or absence of RV dysfunction.
Complications
|
Total, n = 33
|
No RV Dysfunction, n = 19
|
RV Dysfunction, n = 14
|
P Value (chi-square test)
|
Hemorrhage
|
51.50%
|
52.26%
|
50%
|
0.815
|
Heparin Induced Thrombocytopenia
|
15.15%
|
15.79%
|
14.29%
|
0.783
|
Pneumonia
|
69.69%
|
68.42%
|
78.57%
|
0.283
|
Thrombosis/ DVTs
|
30.30%
|
21.05%
|
42.85%
|
0.005
|
Urinary Tract Infection
|
21.21%
|
21.05%
|
21.43%
|
0.950
|
Bacteremia
|
21.21%
|
21.05%
|
21.43%
|
0.953
|
Pneumothorax
|
15.15%
|
15.79%
|
14.29%
|
0.783
|
Pulmonary Embolism
|
15.15%
|
10.53%
|
21.42%
|
0.045
|
Total of 9% (n = 3) patients required placement of percutaneous RVAD. All were female, aged between 31–46 years old. They all had a history of asthma, and one also had a distant history of H1N1 infection for which she had undergone intubation and ventilation. All three patients exhibited severe RV dysfunction characterized by RV FAC < 35% and elevated pulmonary artery pressures (PAPs). Two patients were able to recover from ARDS and were discharged to the inpatient rehabilitation service and later discharged to home. The other did not show any evidence of cardiopulmonary recovery despite a prolong period of support and died when support was withdrawn.
The overall survival rate in this study of our COVID-19 VV ECMO cohort was 39% (n = 13). The RV dysfunction group had a longer duration of mechanical ventilation, mechanical circulatory support, and longer total hospital stay. However, these findings did not reach statistical significance (see Table 4).
Table 4
Outcome data as related to presence or absence of significant RV dysfunction.
Outcomes
|
Total, n = 33
|
No RV Dysfunction, n = 19
|
RV Dysfunction, n = 14
|
P Value
|
Survival to discharge %
|
39.4%
|
42.1%
|
35.7%
|
0.466
|
Mean Duration of mechanical ventilation (days)
|
36.3
|
32.4
|
41.7
|
0.182
|
Mean Duration of mechanical circulatory support (days)
|
27.3
|
20.9
|
35.9
|
0.062
|
Mean Duration of Total Hospital Stay (days)
|
54.9
|
47.0
|
65.6
|
0.153
|