Multi-institutional Analysis of 200 COVID-19 Patients treated with ECMO:Outcomes and Trends

Jacobs et al., The Annals of Thoracic Surgery, doi:10.1016/j.athoracsur.2021.06.026, Jul 2021
Mortality 7% improvement lower risk ← → higher risk HCQ for COVID-19  Jacobs et al.  LATE TREATMENT Is late treatment with HCQ beneficial for COVID-19? Prospective study of 200 patients in the USA No significant difference in mortality c19early.org Jacobs et al., The Annals of Thoracic .., Jul 2021 0 0.5 1 1.5 2+ RR
HCQ for COVID-19
1st treatment shown to reduce risk in March 2020, now with p < 0.00000000001 from 424 studies, used in 59 countries.
Lower risk for mortality, hospitalization, progression, recovery, cases, and viral clearance.
No treatment is 100% effective. Protocols combine treatments.
6,200+ studies for 200+ treatments. c19early.org
Download Meta Analysis
Prospective study of 200 ECMO patients showing no significant difference in unadjusted results for HCQ treatment. Time based confounding is likely because HCQ became increasingly controversial and less used over the time covered (as shown in figure 4), while overall treatment protocols during this period improved dramatically, i.e., more control patients likely come later in the period when treatment protocols were greatly improved.
Standard of Care (SOC) for COVID-19 in the study country, the USA, is very poor with very low average efficacy for approved treatments1. Only expensive, high-profit treatments were approved for early treatment. Low-cost treatments were excluded, reducing the probability of early treatment due to access and cost barriers, and eliminating complementary and synergistic benefits seen with many low-cost treatments. This may explain in part the very high mortality seen in this study. Results may differ in countries with improved SOC.
This study is excluded in the after exclusion results of meta analysis: unadjusted results with no group details; substantial confounding by time likely due to declining usage over the early stages of the pandemic when overall treatment protocols improved dramatically.
Important missing comments or errors? Let us know.
risk of death, 6.6% lower, RR 0.93, p = 0.74, treatment 24 of 46 (52.2%), control 86 of 154 (55.8%), NNT 27.
Effect extraction follows pre-specified rules prioritizing more serious outcomes. Submit updates
Jacobs et al., 6 Jul 2021, prospective, USA, peer-reviewed, 14 authors.
$0 $500 $1,000+ Efficacy vs. cost for COVID-19 treatment protocols c19early.org November 2025 USA Russia Sudan Angola Colombia Kenya Mozambique Vietnam Peru Philippines Spain Brazil Italy France Japan Canada China Uzbekistan Nepal Ethiopia Iran Ghana Mexico South Korea Germany Bangladesh Saudi Arabia Algeria Morocco Yemen Poland India DR Congo Madagascar Thailand Uganda Venezuela Nigeria Egypt Bolivia Taiwan Zambia Fiji Bosnia-Herzegovina Ukraine Côte d'Ivoire Bulgaria Greece Slovakia Singapore Iceland New Zealand Czechia Mongolia Israel Trinidad and Tobago Hong Kong North Macedonia Belarus Qatar Panama Serbia CAR USA favored high-profit treatments.The average efficacy of treatments was very low.High-cost protocols reduce early treatment, andforgo complementary/synergistic benefits. More effective More expensive 75% 50% 25% ≤0%
$0 $500 $1,000+ Efficacy vs. cost for COVID-19treatment protocols worldwide c19early.org November 2025 USA Russia Sudan Angola Colombia Kenya Mozambique Vietnam Peru Philippines Spain Brazil Italy France Japan Canada China Uzbekistan Nepal Ethiopia Iran Ghana Mexico South Korea Germany Bangladesh Saudi Arabia Algeria Morocco Yemen Poland India DR Congo Madagascar Thailand Uganda Venezuela Nigeria Egypt Bolivia Taiwan Zambia Fiji Ukraine Côte d'Ivoire Eritrea Bulgaria Greece Slovakia Singapore New Zealand Malawi Czechia Mongolia Israel Trinidad and Tobago North Macedonia Belarus Qatar Panama Serbia Syria USA favored high-profit treatments.The average efficacy was very low.High-cost protocols reduce early treatment,and forgo complementary/synergistic benefits. More effective More expensive 75% 50% 25% ≤0%
Multi-institutional Analysis of 200 COVID-19 Patients Treated With Extracorporeal Membrane Oxygenation: Outcomes and Trends
MD Jeffrey P Jacobs, MSA, CCP (Emeritus Alfred H Stammers, MD James D St Louis, J W Awori Hayanga, MD Michael S Firstenberg, CCP (Emeritus Linda B Mongero, PhD Eric A Tesdahl, MD Keshava Rajagopal, PhD Faisal H Cheema, MD Kirti Patel, CCP Tom Coley, CCP Anthony K Sestokas, PhD Marvin J Slepian, MD Vinay Badhwar
The Annals of Thoracic Surgery, doi:10.1016/j.athoracsur.2021.06.026
BACKGROUND The role of extracorporeal membrane oxygenation (ECMO) in the management of patients with COVID-19 continues to evolve. The purpose of this analysis is to review our multi-institutional clinical experience involving 200 consecutive patients at 29 hospitals with confirmed COVID-19 supported with ECMO. METHODS This analysis includes our first 200 COVID-19 patients with complete data who were supported with and separated from ECMO. These patients were cannulated between March 17 and December 1, 2020. Differences by mortality group were assessed using c 2 tests for categoric variables and Kruskal-Wallis rank sum tests and Welch's analysis of variance for continuous variables. RESULTS Median ECMO time was 15 days (interquartile range, 9 to 28). All 200 patients have separated from ECMO: 90 patients (45%) survived and 110 patients (55%) died. Survival with venovenous ECMO was 87 of 188 patients (46.3%), whereas survival with venoarterial ECMO was 3 of 12 patients (25%). Of 90 survivors, 77 have been discharged from the hospital and 13 remain hospitalized at the ECMO-providing hospital. Survivors had lower median age (47 versus 56 years, P < .001) and shorter median time from diagnosis to ECMO cannulation (8 versus 12 days, P [ .003). For the 90 survivors, adjunctive therapies on ECMO included intravenous steroids (64), remdesivir (49), convalescent plasma (43), anti-interleukin-6 receptor blockers (39), prostaglandin (33), and hydroxychloroquine (22). CONCLUSIONS Extracorporeal membrane oxygenation facilitates survival of select critically ill patients with COVID-19. Survivors tend to be younger and have a shorter duration from diagnosis to cannulation. Substantial variation exists in drug treatment of COVID-19, but ECMO offers a reasonable rescue strategy.
References
Barbaro, Maclaren, Boonstra, Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry, Lancet
Bartlett, Ogino, Brodie, Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure, ASAIO J
Clerkin, Fried, Raikhelkar, COVID-19 and cardiovascular disease, Circulation
Henry, COVID-19, ECMO, and lymphopenia: a word of caution, Lancet Respir Med
Jacobs, Falasa, Machuca, Extracorporeal membrane oxygenation for patients with refractory COVID-19: what do we know and what do we need to learn?
Jacobs, Stammers, Louis, Extracorporeal membrane oxygenation in the treatment of severe pulmonary and cardiac compromise 8 JACOBS ET AL ECMO AND COVID-19
Kon, Smith, Chang, Extracorporeal membrane oxygenation support in severe COVID-19, Ann Thorac Surg
Madjid, Safavi-Naeini, Solomon, Vardeny, Potential effects of coronaviruses on the cardiovascular system: a review, JAMA Cardiol
Rajagopal, Keller, Akhanti, Advanced pulmonary and cardiac support of COVID-19 patients: emerging recommendations from ASAIO-a "living working document, ASAIO J
Shih, Dimaio, Squiers, Venovenous extracorporeal membrane oxygenation for patients with refractory COVID-19: multicenter experience of referral hospitals in a large health care system
Yang, Yu, Xu, Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study, Lancet Respir Med
DOI record: { "DOI": "10.1016/j.athoracsur.2021.06.026", "ISSN": [ "0003-4975" ], "URL": "http://dx.doi.org/10.1016/j.athoracsur.2021.06.026", "alternative-id": [ "S0003497521011772" ], "assertion": [ { "label": "This article is maintained by", "name": "publisher", "value": "Elsevier" }, { "label": "Article Title", "name": "articletitle", "value": "Multi-institutional Analysis of 200 COVID-19 Patients Treated With Extracorporeal Membrane Oxygenation: Outcomes and Trends" }, { "label": "Journal Title", "name": "journaltitle", "value": "The Annals of Thoracic Surgery" }, { "label": "CrossRef DOI link to publisher maintained version", "name": "articlelink", "value": "https://doi.org/10.1016/j.athoracsur.2021.06.026" }, { "label": "Content Type", "name": "content_type", "value": "article" }, { "label": "Copyright", "name": "copyright", "value": "© 2022 by The Society of Thoracic Surgeons" } ], "author": [ { "affiliation": [], "family": "Jacobs", "given": "Jeffrey P.", "sequence": "first" }, { "affiliation": [], "family": "Stammers", "given": "Alfred H.", "sequence": "additional" }, { "affiliation": [], "family": "St Louis", "given": "James D.", "sequence": "additional" }, { "affiliation": [], "family": "Hayanga", "given": "J. W. Awori", "sequence": "additional" }, { "affiliation": [], "family": "Firstenberg", "given": "Michael S.", "sequence": "additional" }, { "affiliation": [], "family": "Mongero", "given": "Linda B.", "sequence": "additional" }, { "affiliation": [], "family": "Tesdahl", "given": "Eric A.", "sequence": "additional" }, { "affiliation": [], "family": "Rajagopal", "given": "Keshava", "sequence": "additional" }, { "affiliation": [], "family": "Cheema", "given": "Faisal H.", "sequence": "additional" }, { "affiliation": [], "family": "Patel", "given": "Kirti", "sequence": "additional" }, { "affiliation": [], "family": "Coley", "given": "Tom", "sequence": "additional" }, { "affiliation": [], "family": "Sestokas", "given": "Anthony K.", "sequence": "additional" }, { "affiliation": [], "family": "Slepian", "given": "Marvin J.", "sequence": "additional" }, { "affiliation": [], "family": "Badhwar", "given": "Vinay", "sequence": "additional" } ], "container-title": "The Annals of Thoracic Surgery", "container-title-short": "The Annals of Thoracic Surgery", "content-domain": { "crossmark-restriction": true, "domain": [ "clinicalkey.fr", "clinicalkey.jp", "clinicalkey.com.au", "clinicalkey.es", "clinicalkey.com", "annalsthoracicsurgery.org", "elsevier.com", "sciencedirect.com" ] }, "created": { "date-parts": [ [ 2021, 7, 6 ] ], "date-time": "2021-07-06T14:48:38Z", "timestamp": 1625582918000 }, "deposited": { "date-parts": [ [ 2022, 4, 19 ] ], "date-time": "2022-04-19T18:04:46Z", "timestamp": 1650391486000 }, "indexed": { "date-parts": [ [ 2023, 10, 20 ] ], "date-time": "2023-10-20T04:46:49Z", "timestamp": 1697777209114 }, "is-referenced-by-count": 10, "issue": "5", "issued": { "date-parts": [ [ 2022, 5 ] ] }, "journal-issue": { "issue": "5", "published-print": { "date-parts": [ [ 2022, 5 ] ] } }, "language": "en", "license": [ { "URL": "https://www.elsevier.com/tdm/userlicense/1.0/", "content-version": "tdm", "delay-in-days": 0, "start": { "date-parts": [ [ 2022, 5, 1 ] ], "date-time": "2022-05-01T00:00:00Z", "timestamp": 1651363200000 } } ], "link": [ { "URL": "https://api.elsevier.com/content/article/PII:S0003497521011772?httpAccept=text/xml", "content-type": "text/xml", "content-version": "vor", "intended-application": "text-mining" }, { "URL": "https://api.elsevier.com/content/article/PII:S0003497521011772?httpAccept=text/plain", "content-type": "text/plain", "content-version": "vor", "intended-application": "text-mining" } ], "member": "78", "original-title": [], "page": "1452-1460", "prefix": "10.1016", "published": { "date-parts": [ [ 2022, 5 ] ] }, "published-print": { "date-parts": [ [ 2022, 5 ] ] }, "publisher": "Elsevier BV", "reference": [ { "DOI": "10.1161/CIRCULATIONAHA.120.046941", "article-title": "COVID-19 and cardiovascular disease", "author": "Clerkin", "doi-asserted-by": "crossref", "first-page": "1648", "journal-title": "Circulation", "key": "10.1016/j.athoracsur.2021.06.026_bib2", "volume": "141", "year": "2019" }, { "DOI": "10.1001/jamacardio.2020.1286", "article-title": "Potential effects of coronaviruses on the cardiovascular system: a review", "author": "Madjid", "doi-asserted-by": "crossref", "first-page": "831", "journal-title": "JAMA Cardiol", "key": "10.1016/j.athoracsur.2021.06.026_bib3", "volume": "5", "year": "2020" }, { "DOI": "10.1097/MAT.0000000000001185", "article-title": "Extracorporeal membrane oxygenation in the treatment of severe pulmonary and cardiac compromise in coronavirus disease 2019: experience with 32 patients", "author": "Jacobs", "doi-asserted-by": "crossref", "first-page": "722", "journal-title": "ASAIO J", "key": "10.1016/j.athoracsur.2021.06.026_bib4", "volume": "66", "year": "2020" }, { "DOI": "10.1016/S2213-2600(20)30079-5", "article-title": "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study", "author": "Yang", "doi-asserted-by": "crossref", "first-page": "475", "journal-title": "Lancet Respir Med", "key": "10.1016/j.athoracsur.2021.06.026_bib5", "volume": "8", "year": "2020" }, { "DOI": "10.1016/S2213-2600(20)30119-3", "article-title": "COVID-19, ECMO, and lymphopenia: a word of caution", "author": "Henry", "doi-asserted-by": "crossref", "first-page": "e24", "journal-title": "Lancet Respir Med", "key": "10.1016/j.athoracsur.2021.06.026_bib6", "volume": "8", "year": "2020" }, { "DOI": "10.1016/j.athoracsur.2020.07.002", "article-title": "Extracorporeal membrane oxygenation support in severe COVID-19", "author": "Kon", "doi-asserted-by": "crossref", "first-page": "537", "journal-title": "Ann Thorac Surg", "key": "10.1016/j.athoracsur.2021.06.026_bib7", "volume": "111", "year": "2021" }, { "DOI": "10.1016/S0140-6736(20)32008-0", "article-title": "Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry", "author": "Barbaro", "doi-asserted-by": "crossref", "first-page": "1071", "journal-title": "Lancet", "key": "10.1016/j.athoracsur.2021.06.026_bib8", "volume": "396", "year": "2020" }, { "DOI": "10.1097/MAT.0000000000001173", "article-title": "Initial ELSO guidance document: ECMO for COVID-19 patients with severe cardiopulmonary failure", "author": "Bartlett", "doi-asserted-by": "crossref", "first-page": "472", "journal-title": "ASAIO J", "key": "10.1016/j.athoracsur.2021.06.026_bib11", "volume": "66", "year": "2020" }, { "DOI": "10.1097/MAT.0000000000001180", "article-title": "Advanced pulmonary and cardiac support of COVID-19 patients: emerging recommendations from ASAIO—a “living working document", "author": "Rajagopal", "doi-asserted-by": "crossref", "first-page": "588", "journal-title": "ASAIO J", "key": "10.1016/j.athoracsur.2021.06.026_bib12", "volume": "66", "year": "2020" }, { "DOI": "10.1016/j.jtcvs.2020.11.073", "article-title": "Venovenous extracorporeal membrane oxygenation for patients with refractory coronavirus disease 2019 (COVID-19): multicenter experience of referral hospitals in a large health care system", "author": "Shih", "doi-asserted-by": "crossref", "first-page": "1071", "journal-title": "J Thorac Cardiovasc Surg", "key": "10.1016/j.athoracsur.2021.06.026_bib13", "volume": "163", "year": "2022" }, { "DOI": "10.1016/j.jtcvs.2020.11.128", "article-title": "Commentary: extracorporeal membrane oxygenation for patients with refractory coronavirus disease 2019 (COVID-19): what do we know and what do we need to learn?", "author": "Jacobs", "doi-asserted-by": "crossref", "first-page": "1080", "journal-title": "J Thorac Cardiovasc Surg", "key": "10.1016/j.athoracsur.2021.06.026_bib14", "volume": "163", "year": "2022" } ], "reference-count": 11, "references-count": 11, "relation": {}, "resource": { "primary": { "URL": "https://linkinghub.elsevier.com/retrieve/pii/S0003497521011772" } }, "score": 1, "short-title": [], "source": "Crossref", "subject": [ "Cardiology and Cardiovascular Medicine", "Pulmonary and Respiratory Medicine", "Surgery" ], "subtitle": [], "title": "Multi-institutional Analysis of 200 COVID-19 Patients Treated With Extracorporeal Membrane Oxygenation: Outcomes and Trends", "type": "journal-article", "update-policy": "http://dx.doi.org/10.1016/elsevier_cm_policy", "volume": "113" }
Late treatment
is less effective
Please send us corrections, updates, or comments. c19early involves the extraction of 200,000+ datapoints from thousands of papers. Community updates help ensure high accuracy. Treatments and other interventions are complementary. All practical, effective, and safe means should be used based on risk/benefit analysis. No treatment or intervention is 100% available and effective for all current and future variants. We do not provide medical advice. Before taking any medication, consult a qualified physician who can provide personalized advice and details of risks and benefits based on your medical history and situation. IMA and WCH provide treatment protocols.
  or use drag and drop   
Submit    
Post
Share
@CovidAnalysis
FAQ
Public domain CC0 1.0