PM1025: Role of Transcutaneous ECMO in Multi-system Inflammatory Syndrome in Children in the Setting of COVID-19

Introduction: Multi-system Inflammatory Syndrome in Children (MIS-C) in the setting of COVID-19 can be associated with severe cardiopulmonary dysfunction needing extracorporeal membrane oxygenation (ECMO) support. We describe our institutional approach and the first reported series of percutaneous ECMO in pediatric patients with MIS-C.

Case Description: Demographic characteristics, comorbidities, symptoms, echocardiogram findings, procedure types, and outcomes for the five MIS-C patients who underwent ECMO cannulation are presented in Table 1. Presenting symptoms and signs were consistent with heart failure secondary to MIS-C in the setting of recent COVID-19 exposures and positive COVID-19 antibodies. All patients were treated with corticosteroids and IVIG for MIS-C. Echocardiograms prior to ECMO cannulation demonstrated severely decreased left ventricular systolic function. Early in the pandemic, patients 1 and 2 underwent open surgical Veno-Arterial (VA) ECMO. After implementing our institutional approach, patients 3-5 underwent percutaneous VA-ECMO cannulation via ultrasound-guided vascular access. It involves insertion of a venous cannula into a peripheral vein that is advanced into the right atrium, insertion of an arterial cannula into a peripheral artery that is advanced to the descending aorta, and attachment of an additional reperfusion cannula to the arterial cannula via a nearby artery. All patients except for the first underwent atrial septostomy (Figure 1) following ECMO cannulation to decompress the left atrium. Open surgical ECMO patients had longer hospitalization and ICU days with residual sequelae needing transition to rehabilitation facilities. Time from activation of ECMO to cannulation and flow was significantly shorter in the percutaneous ECMO group. All patients survived and recovered their cardiac function.

Discussion: This series reminds the clinician of the rare but serious consequence of severe rapid cardiopulmonary deterioration associated with COVID-19 in children and highlights the life-saving role of ECMO in these patients while anticipating reversal of the inflammatory response. The challenge of the need for swift cannulation makes the transcutaneous route with ultrasound guidance a good alternative to open cannulation from a technique perspective. With newer variants on the horizon and vaccine adoption rates in the pediatric population still low, pediatric patients become the most vulnerable group in society necessitating an organized approach to management of cardiorespiratory failure from MIS-C. ECMO should be strongly considered in the cohort of MIS-C patients since the inflammatory process is transient. The collaboration of interdisciplinary providers to implement a tailored institutional approach to the specific pediatric patient based on size and disease process is essential for improving outcomes.

Conclusion: The use of percutaneous ECMO in pediatric patients with MIS-C is feasible and is a good adjunct to open surgical ECMO. Atrial septostomy for left atrial decompression should be considered in this patient population. A programmatic approach to specific disease processes like MIS-C is essential for good outcomes.