Cerebrovascular Complications of COVID-19 on Venovenous Extracorporeal Membrane Oxygenation.

Objectives: Evidence of cerebrovascular complications in COVID-19 requiring venovenous extracorporeal membrane oxygenation (ECMO) is limited. Our study aims to characterize the prevalence and risk factors of stroke secondary to COVID-19 in patients on venovenous ECMO.
Design: We analyzed prospectively collected observational data, using univariable and multivariable survival modeling to identify risk factors for stroke. Cox proportional hazards and Fine-Gray models were used, with death and discharge treated as competing risks.
Setting: Three hundred eighty institutions in 53 countries in the COVID-19 Critical Care Consortium (COVID Critical) registry.
Patients: Adult COVID-19 patients who were supported by venovenous ECMO.
Interventions: None.
Measurements and Main Results: Five hundred ninety-five patients (median age [interquartile range], 51 yr [42-59 yr]; male: 70.8%) had venovenous ECMO support. Forty-three patients (7.2%) suffered strokes, 83.7% of which were hemorrhagic. In multivariable survival analysis, obesity (adjusted hazard ratio [aHR], 2.19; 95% CI, 1.05-4.59) and use of vasopressors before ECMO (aHR, 2.37; 95% CI, 1.08-5.22) were associated with an increased risk of stroke. Forty-eight-hour post-ECMO Pa co2 -pre-ECMO Pa co2 /pre-ECMO Pa co2 (relative ΔPa co2 ) of negative 26% and 48-hour post-ECMO Pa o2 -pre-ECMO Pa o2 /pre-ECMO Pa o2 (relative ΔPa o2 ) of positive 24% at 48 hours of ECMO initiation were observed in stroke patients in comparison to relative ΔPa co2 of negative 17% and relative ΔPa o2 of positive 7% in the nonstroke group. Patients with acute stroke had a 79% in-hospital mortality compared with 45% mortality for stroke-free patients.
Conclusions: Our study highlights the association of obesity and pre-ECMO vasopressor use with the development of stroke in COVID-19 patients on venovenous ECMO. Also, the importance of relative decrease in Pa co2 and moderate hyperoxia within 48 hours after ECMO initiation were additional risk factors.
Competing Interests: Drs. Kelly’s, Heinsar’s, and Suen’s institutions received funding from the Bill and Melinda Gates Foundation. Drs. Kelly, Heinsar, Suen, and Fraser received support for article research from the Bill and Melinda Gates Foundation. Dr. Heinsar received funding from The Prince Charles Hospital Foundation. Dr. Suen is funded by the Advance Queensland fellowship program. Dr. Li Bassi is a recipient of the Biomedicine International training research programme for excellent clinician-scientists (BITRECS) fellowship; the “BITRECS” project has received funding from the European Union’s Horizon 2020 research and innovation program under the Marie Skłodowska-Curie grant agreement no. 754550 and from the “La Caixa” Foundation (identification number 100010434), under the agreement LCF/PR/GN18/50310006. Dr. Jacobs received funding from SpecialtyCare and the American Academy of Dermatology. Dr. Fraser’s institution received funding from Fisher & Paykel, Mallinckrodt Pharmaceuticals, and Lendlease; he received funding from De Motu Cordis, Philips Electronics, International Society for Heart and Lung Transplantation, and General Practice Training Queensland. Dr. Lorusso’s institution received funding from Medtronic, LivaNova, Getinge, Eurosets, Corcym, Hemocue, and Xenios. Dr. Cho received support for article research from the National Institutes of Health; he is funded by the National Heart, Lung, and Blood Institute 1K23HL157610. The remaining authors have disclosed that they do not have any potential conflicts of interest.
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