Impact of structured physical therapy protocol among heart transplant recipients while on intra-aortic balloon pump in the pretransplant period.

BACKGROUND: Use of prolonged femoral intra-aortic balloon pump support limits the mobility of patients awaiting heart transplant. We assessed the safety and outcomes of a structured, tilting physical therapy protocol in patients supported by intra-aortic balloon pumps while awaiting transplant. METHODS: We retrospectively reviewed five years of transplant patients. Eighteen patients received femoral intra-aortic balloon support, a heart transplant, and met all eligibility criteria. We compared complications and outcomes between patients who received the structured, tilting physical therapy (Protocol Group) and those that received standard of care (Control Group). RESULTS: Complications were not significantly different between groups. The majority of the Protocol Group were discharged to home (10/12), while half (3/6) of the Control Group were discharged to a rehabilitation facility. Post-transplant length of stay was significantly less in the Protocol Group (median 16 vs. 28 days, p = 0.03). CONCLUSION: Despite the small number analyzed, the data indicates that the structured, tilting physical therapy protocol led to a significantly reduced length of stay post-transplantation. Importantly, use of the protocol did not result in access site complications, thrombosis, or arrhythmias in the majority of the patients.

Veno-arterial extracorporeal membrane oxygenation for post-infarction ventricular septal defect in a low-volume center.

Managing patients with post-ischaemic ventricular septal defects (VSD) and postcardiotomy cardiogenic shock can be extremely challenging in a low-volume cardiac surgery unit. We present a case of a 68-year-old patient who received veno-arterial extracorporeal membrane oxygenation support due to cardiogenic shock after VSD repair. The patient was successfully weaned off support after 86 h. In the postoperative period, mediastinitis occurred, and negative pressure wound therapy was instituted.

The use of veno-arterial extracorporeal membrane oxygenation in the octogenarian population: A single-center experience.

INTRODUCTION: Advanced age is a known risk factor for poor outcomes after veno-arterial extracorporeal membrane oxygenation (V-A ECMO) for cardiac support. The use of ECMO support in patients over the age of 80 is controversial, and sometimes its use is contraindicated. We aimed to assess the use of ECMO in octogenarian patients to determine survival and complication rates. METHODS: A single-center, retrospective analysis was completed at a large, urban academic medical center. Patients requiring V-A ECMO support between December of 2012 and November of 2019 were included as long as the patient was at least 80 years of age at the time of cannulation. Post cardiotomy shock patients were excluded. RESULTS: A total of 46 patients met eligibility criteria; all received V-A ECMO support. Overall, the majority of patients (71.7%; 33/46) survived to decannulation, and 43.5% (20/46) survived to discharge. Patients who were previously rescued from percutaneous interventions tend to have a better survival than other patients (p = .06). The most common complications were renal and hemorrhagic. CONCLUSIONS: We demonstrated that advanced age alone should not disqualify patients from cannulating and supporting with V-A ECMO.

Inter-Institutional Collaboration Between Quaternary and Tertiary Hospitals: Cardiac Surgery Impact.

BACKGROUND: An inter-institutional collaboration between a quaternary hospital (QH) with a high volume of cardiac surgery and a community-based, tertiary hospital (TH) with a newly established cardiac surgery program was established. METHODS: We retrospectively reviewed data of patients admitted to the TH between September 2015 and June 2017 for cardiac surgery. The decision to transfer a patient to the QH was based on a Society of Thoracic Surgeon-Predicted Risk of Mortality (STS-PROM) score of ≥ 3%, the potential need for hemodialysis, and other risk factors. The same team of surgeons performed operations at both hospitals. We analyzed the perioperative outcomes of the patients and the referral pattern. RESULTS: A total of 116 patients met eligibility criteria; 105 underwent surgery at the TH, while 11 were transferred to the QH. Among the 11 patients transferred to the QH, eight had a score of  3% (median = 8.2 [IQR 5.7-25.0]). The patients transferred to the QH prior to surgery had a significantly higher STS-PROM score (P = ≤ .001). Overall, the mortality of patients who underwent surgery at the TH was 0.9% (1/105); while surgeries at the QH had a mortality rate of 0% (0/11). CONCLUSION: The collaborative effort between high-volume cardiac surgery programs and emerging community-based hospitals showed acceptable outcomes in perioperative cardiac surgical mortality. Elevated STS-PROM scores (>3%), previous sternotomy and anticipation of coagulopathy, and low left ventricular ejection fraction or dilated ventricles are factors that influenced the need to transfer from a TH to QH.

COVID-19 and Blood Clots: A Report of Massive Pulmonary Embolism in COVID-19 Patient Supported on Veno-Venous ECMO and the Utility of Thrombolysis.

COVID-19 morbidity and mortality are not equivalent to other etiologies of acute respiratory distress syndrome (ARDS) as fulminant activation of coagulation can occur, thereby resulting in widespread microvascular thrombosis and consumption of coagulation factors. A 53-year-old female presented to an emergency center on two occasions with progressive gastrointestinal and respiratory symptoms. She was diagnosed with COVID-19 pneumonia and admitted to a satellite intensive care unit with hypoxemic respiratory failure. She was intubated and mechanically ventilated, but her ARDS progressed over the next 48 hours. The patient was emergently cannulated for veno-venous extracorporeal membrane oxygenation (V-V ECMO) and transferred to our hospital. She was in profound shock requiring multiple vasopressors for hemodynamic support with worsening clinical status on arrival. On bedside echocardiography, she was found to have a massive pulmonary embolism with clot-in-transit visualized in the right atrium and right ventricular outflow tract. After a multidisciplinary discussion, systemic thrombolytic therapy was administered. The patient's hemodynamics improved and vasopressors were discontinued. This case illustrates the utility of bedside echocardiography in shock determination, the need for continued vigilance in the systematic evaluation of unstable patients in the intensive care unit, and the use of systemic thrombolytics during V-V ECMO in a novel disease process with evolving understanding.

Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support.

BACKGROUND: Respiratory failure (RF) is a common cause of death and morbid complication in trauma patients. Extracorporeal membrane oxygenation (ECMO) is increasingly used in adults with RF refractory to invasive mechanical ventilation. However, use of ECMO remains limited for this patient population as they often have contraindications for anticoagulation. STUDY DESIGN: Medical records were retroactively searched for all adult patients who were admitted to the trauma service and received veno-venous ECMO (VV ECMO) support between June 2015 and August 2018. Survival to discharge and ECMO-related complications were collected and analyzed. RESULTS: Fifteen patients from a large Level I trauma center met the criteria. The median PaO2/FiO2 ratio was 53.0 (IQR, 27.0-76.0), median injury severity score was 34.0 (IQR, 27.0-43.0), and the median duration of ECMO support was 11 days (IQR, 7.5-20.0). For this cohort, the survival-to-discharge rate was 87% (13/15). The incidence of neurologic complications was 13%, and deep vein thrombosis was reported in two cases (13%). CONCLUSIONS: Survival rates of trauma patients in this study are equivalent to, or may exceed, those of non-trauma patients who receive ECMO support for other types of RF. With the employment of a multidisciplinary team assessment and proper patient selection, early cannulation, traumatic RF may be safely supported with VV ECMO in experienced centers.

Partial anomalous pulmonary venous return after orthotopic heart transplantation case report.

BACKGROUND: Partial anomalous pulmonary venous return (PAPVR) is a congenital heart defect. Reports of repair and treatment in pediatric cases have been published, but incidence of PAPVR in adults is not common. To our knowledge, there has not been a diagnosis of left-sided PAPVR after a heart transplant an in adult patient. CASE PRESENTATION: A 62-year-old patient with ischemic cardiomyopathy and systolic heart failure underwent orthotopic heart transplantation. The immediate post-operative course was remarkable for an elevated cardiac index and pulmonary artery pressures as well as decreased systemic vascular resistance. The post-operative echocardiogram did not reveal an intra-cardiac shunt. However, computed tomographic angiography (CTA) showed a left superior pulmonary vein draining into the innominate vein. Operative repair of the left superior pulmonary venous connection to the left atrial appendage was completed under cardiopulmonary bypass with beating heart. Her hemodynamics improved immediately, and she had an unremarkable postoperative course. CONCLUSIONS: While uncommon, any patient with a high cardiac output and abnormal hemodynamics after heart transplant should be evaluated for the existence of a shunt. While not a part of all traditional preoperative imaging protocols, a chest CTA should be considered if PAPVR is suspected as it can both diagnose the condition and enable a plot of the corrective course of surgical action.

Association Between Early Tracheostomy and Delirium in Older Adults in the United States.

OBJECTIVES: Early tracheostomy (fewer than eight days after intubation) is associated with shorter length of stay in the intensive care unit and shorter duration of mechanical ventilation. Studies assessing the association between early tracheostomy and incidence of delirium, however, are lacking. This investigation sought to fill this gap. DESIGN: Retrospective cross-sectional study. SETTING: Multi-institutional acute care facilities in the United States. PARTICIPANTS: Data were derived from the National Inpatient Sample data from 2010 to 2014. Included patients were 65 or older and underwent both intubation and tracheostomy during the hospitalization. The authors excluded patients who underwent multiple intubations or tracheostomy procedures. INTERVENTIONS: Early tracheostomy versus non-early tracheostomy. RESULTS: In total, 23,310 patients were included, of whom 24.8% underwent early tracheostomy. From multivariate logistic regression, early tracheostomy was associated with lower odds of having a delirium diagnosis (odds ratio [OR] 0.77, p < 0.00001) across all admission classifications. Upon subgroup analysis, early tracheostomy was associated significantly with lower odds of having delirium for patients admitted with medical (OR 0.74, p < 0.00001) and nonsurgical injury admissions (OR 0.74, p = 0.00116). CONCLUSIONS: Early tracheostomy was associated significantly with lower odds of delirium among all patients studied. This association held true across medical and nonsurgical subgroups.

Granulomatous fungal and non-tuberculous mycobacterial infestation complicating chronic lung disease: Outcomes in patients undergoing lung transplantation.

INTRODUCTION: Granulomatous infections are common in patients with chronic lung disease. We aim to study the incidence and clinicopathological features of granulomatous infections in a cohort of patients undergoing lung transplantation for end-stage chronic lung disease. METHODS: Pathology reports of 50 explanted native lungs of patients who underwent lung transplantation since 2015 at our institution were reviewed. Four cases with granulomatous lesions were identified. Correlation was made with clinical findings in the 4 cases. RESULTS: The granulomatous infections include non-necrotizing cryptococcal pneumonitis (case 1), necrotizing pneumonia due to Scedosporium sp. and Mycobacterium avium Complex (MAC) (Cases 2 and 3), and invasive Aspergillus pneumonia (Case 4). One patient received pre-transplant fungal prophylaxis (Case 4). Post-transplant infectious complications included invasive (Cases 2 and 4) and non-invasive (Case 1) fungal infections and bacterial pneumonia (Cases 1 and 2). Two patients (Cases 3 and 4) developed acute cellular rejection (ACR) in the first 30 days. The third patient (Case 1) was identified with ACR in the 9 months post-transplant and chronic lung allograft dysfunction at 29 months. In terms of mortality, 1 patient (Case 1) died at 30 months post-transplant from pseudomonal sepsis and chronic graft failure. Two patients with invasive fungal infections (Cases 2 and 4) are on secondary prophylaxis and doing well. One patient (Case 3) remains infection-free and on MAC prophylaxis. CONCLUSIONS: In our case series, patients with chronic lung diseases with superimposed granulomatous infestations frequently experienced post-transplant complications. These include invasive infections and repeat ACRs that predispose patients to chronic graft dysfunction. Pre- and post-transplant antifungal prophylaxis reduces fungal load and complication risk post-transplant.

Extracorporeal Membrane Oxygenation Rescue for Severe Aspiration Pneumonitis in Two Patients after Roux-en-y Gastric Bypass Procedure.

Roux-en-y gastric bypass (RYGB) is one of the most common weight loss surgical procedures performed in the United States. Early post-operative small bowel obstruction is a rare but potentially morbid, complication of RYGB. We report two patients who underwent RYGB and required subsequent treatment for a post-operative small bowel obstruction. Their post-operative course was complicated by severe aspiration pneumonitis leading to hypoxemic respiratory failure requiring rescue with femoral veno-venous extracorporeal membrane oxygenation (V-V ECMO). Both patients were successfully extubated, weaned off V-V ECMO support, and discharged to home. These cases highlight the potential role of V-V ECMO for patients who have undergone RYGB and develop severe aspiration pneumonitis. They also highlight the need for cautionary use of gastrografin in RYGB patients. Early engagement of a multidisciplinary team experienced with adult ECMO is vital for favorable patient outcomes.

Inter-hospital COVID ECMO air transportation.

The Coronavirus Disease 2019 (COVID-19) pandemic has required rapid and effective protocol adjustments at every level of healthcare. The use of extracorporeal membrane oxygenation (ECMO) is pivotal to COVID-19 treatment in cases of refractory hypoxemic hypercapnic respiratory failure. As such, our large, metropolitan air ambulance system in conjunction with our experts in advanced cardiopulmonary therapies modified protocols to assist peripheral hospitals in evaluation, cannulation and initiation of ECMO for rescue and air transportation of patients with COVID-19 to our quaternary center. The detailed protocol is described alongside initial data of its use. To date, 14 patients have been placed on ECMO support at an outside facility and successfully transported via helicopter to our hub hospital using this protocol.

Intrapericardial Left Ventricular Assist Device for Advanced Heart Failure.

BACKGROUND: Mechanical circulatory support with a left ventricular assist device (LVAD) is an established treatment for patients with advanced heart failure. We compared a newer LVAD design (a small intrapericardial centrifugal-flow device) against existing technology (a commercially available axial-flow device) in patients with advanced heart failure who were ineligible for heart transplantation. METHODS: We conducted a multicenter randomized trial involving 446 patients who were assigned, in a 2:1 ratio, to the study (centrifugal-flow) device or the control (axial-flow) device. Adults who met contemporary criteria for LVAD implantation for permanent use were eligible to participate in the trial. The primary end point was survival at 2 years free from disabling stroke or device removal for malfunction or failure. The trial was powered to show noninferiority with a margin of 15 percentage points. RESULTS: The intention-to treat-population included 297 participants assigned to the study device and 148 participants assigned to the control device. The primary end point was achieved in 164 patients in the study group and 85 patients in the control group. The analysis of the primary end point showed noninferiority of the study device relative to the control device (estimated success rates, 55.4% and 59.1%, respectively, calculated by the Weibull model; absolute difference, 3.7 percentage points; 95% upper confidence limit, 12.56 percentage points; P=0.01 for noninferiority). More patients in the control group than in the study group had device malfunction or device failure requiring replacement (16.2% vs. 8.8%), and more patients in the study group had strokes (29.7% vs. 12.1%). Quality of life and functional capacity improved to a similar degree in the two groups. CONCLUSIONS: In this trial involving patients with advanced heart failure who were ineligible for heart transplantation, a small, intrapericardial, centrifugal-flow LVAD was found to be noninferior to an axial-flow LVAD with respect to survival free from disabling stroke or device removal for malfunction or failure. (Funded by HeartWare; ENDURANCE ClinicalTrials.gov number, NCT01166347 .).

Risk of pump thrombosis and stroke in patients with continuous-flow left ventricular assist devices and gastrointestinal bleeding.

Gastrointestinal (GI) bleeding is a common complication following the placement of continuous-flow left ventricular assist devices (LVADs) in patients with advanced heart failure. Secondary events arising as a result of GI bleeding have not been well-described. Furthermore, attribution of these events to bleeding is complicated by the interruption or de-intensification of antithrombotic therapy, while bleeding is controlled. The purpose of this study was to assess the incidence of pump thrombosis and ischemic stroke in patients with LVADs who experience GI bleeding, while on support. This was a single-center, retrospective, observational cohort study of consecutive patients with LVADs implanted from January 2012 to June 2018. Patients were assigned to comparator groups based on whether they experienced GI bleeding while on LVAD support. The primary endpoint assessed was the composite of pump thrombosis or ischemic stroke. Secondary endpoints assessed included incidence of pump thrombosis or ischemic stroke. A total of 250 patients were included after screening for exclusion criteria, 101 (40.4%) in the GI bleeding group, and 149 (59.6%) in the non-bleeding group. The incidence of pump thrombosis or ischemic stroke was not significantly greater in patients experiencing GI bleeding [23 (22.8%) vs. 21 (14.1%); P = .09]; however, the incidence of ischemic stroke alone was significantly greater [17 (16.8%) vs. 10 (6.7%); P = .01]. We conclude that GI bleeding in LVAD patients may be associated with a greater risk of ischemic stroke.

Tracheostomy while on Extracorporeal Membrane Oxygenation: A Comparison of Percutaneous and Open Procedures.

Although the ideal timing of tracheostomy for critically ill patients is controversial, transitioning from an endotracheal tube can be beneficial. Concerns arise for patients under extracorporeal membrane oxygenation (ECMO) support. Studies have described percutaneous and open tracheostomy approaches for critically ill patients but, to our knowledge, have not compared the two specifically in ECMO patients. This study analyzed safety and aimed to identify if there was a difference in major bleeding or other tracheostomy-associated complications. A single-center retrospective cohort study of all patients who received tracheostomy while on ECMO from July 2013 to May 2019 was completed. The primary endpoint was a significant difference in the incidence of a major bleeding adverse event at 48 hours. Secondary endpoints included differences in the incidence of complications (e.g., procedure-related mortality, ECMO decannulation, tracheal/esophageal injury, and pneumothorax/pneumomediastinum) and survival to discharge. A secondary analysis separated the groups further by comparing those with bleeding events and those without. The study included 27 ECMO patients: 16 (59%) in the percutaneous arm and 11 in the open arm. The median number of ECMO days before tracheostomy was 10 vs. 13, respectively. There were no statistically significant differences between the two groups for major bleeding events (percutaneous 44% vs. open 27%, p = .45), procedure-related mortality, or procedure-related complications. Both percutaneous and open tracheostomies in patients on ECMO require a multidisciplinary approach to minimize adverse effects. Major bleeding does occur, but there was no statistically significant correlation between bleeding events and the type of the tracheostomy approach. Thus, both open and percutaneous tracheostomy approaches have a favorable safety profile.

Extracorporeal Membrane Oxygenation Utility in Postpartum Patients.

Although extracorporeal membrane oxygenation (ECMO) has been used in many different populations, its use in pregnant or postpartum patients has not been widely studied. This article reviews the ECMO experience in this population at a large urban hospital. Electronic medical records for all pregnant or postpartum patients who required ECMO between 2012 and 2019 were retrospectively reviewed. Data on clinical characteristics, outcomes, and complications were gathered. Comparisons between survivors and nonsurvivors were completed. Ten postpartum patients were identified. The patients presented as follows: four with cardiac arrest, one with a massive pulmonary embolism, three with acute respiratory distress syndrome (ARDS), one with combined ARDS and cardiogenic shock, and one with suspected amniotic embolism. Survival to decannulation was 70%, and survival to discharge was 60%. When comparing survivors vs. nonsurvivors, ECMO survivors tended to have shorter support times vs. nonsurvivors. Otherwise, no differences were noted in age, mechanical ventilation time, or length of stay. Disseminated intravascular coagulation was a common phenomenon in this patient cohort. After initiation of ECMO, elevated serum lactate levels, lower systolic blood pressure, and acute renal failure were predictors of mortality. In a single institution at a large metroplex, we present data regarding the use of ECMO in postpartum patients. ECMO can be successfully used in selected postpartum patients with severe cardiac or respiratory dysfunction. Multidisciplinary collaboration on a regular basis will streamline the ECMO referral in a timely manner. Furthermore, larger studies are indicated to understand the utility of ECMO in larger cohorts.

Transcatheter aortic valve implantation with a Sapien 3 Commander 20 mm valves in patients with degenerated 19 mm bioprosthetic aortic valve.

INTRODUCTION: Transcatheter aortic valve implantation (TAVI) in patients with degenerated bioprosthetic aortic valve has been successfully performed as an alternative to surgery. We describe our initial experience of valve-in-valve TAVI in five patients, using new generation Edwards Sapien 3 transcatheter heart valves implanted into degenerated 19 mm bioprosthetic valves. 20-mm Edwards S3 valves were offered for compassionate use. All patients had significant aortic valve stenosis. METHODS AND RESULTS: The main vascular access was achieved and pre-closed with two Proglide closure devices in one patient and Prostar closure devices in four patients. For each TAVI procedure an Edwards 14 French sheath was inserted without complication and sutured in place. The Sapien 3 Commander delivery system was inserted and the valve was aligned in the descending aorta. The 20-mm Sapien 3 valve was deployed with slow continuous inflation during rapid right ventricular pacing. The cranial edge of the Edwards S3 valve was aligned with the cranial radiopaque markers of bioprosthesis to minimize paravalvular leak. Post-deployment angiography, transesophageal echocardiography and aortogram confirmed absence of mild aortic insufficiency and no increase in trans-aortic gradient when compared to a naïve 19 mm bioprosthetic valve. CONCLUSION: Valve-in-valve TAVI with the Edwards S3 transcatheter heart valve for degenerative bioprosthetic aortic valves is technically feasible. The proper position of the stented valve minimizes the risk for post-procedure paravalvular insufficiency and provides good transaortic pressure gradient. © 2016 Wiley Periodicals, Inc.

Coronary artery bypass grafting to treat coronary arterial occlusion incurred during orthotopic heart transplantation.

We report a case of left circumflex coronary artery occlusion sustained during orthotopic heart transplantation. Emergent coronary artery bypass grafting was performed, with recovery of cardiac function. The etiology and management of this complication are reviewed.

Low-Flow Extracorporeal Carbon Dioxide Removal Using the Hemolung Respiratory Dialysis System® to Facilitate Lung-Protective Mechanical Ventilation in Acute Respiratory Distress Syndrome.

Extracorporeal carbon dioxide removal (ECCO2R) permits reductions in alveolar ventilation requirements that the lungs would otherwise have to provide. This concept was applied to a case of hypercapnia refractory to high-level invasive mechanical ventilator support. We present a case of an 18-year-old man who developed post-pneumonectomy acute respiratory distress syndrome (ARDS) after resection of a mediastinal germ cell tumor involving the left lung hilum. Hypercapnia and hypoxemia persisted despite ventilator support even at traumatic levels. ECCO2R using a miniaturized system was instituted and provided effective carbon dioxide elimination. This facilitated establishment of lung-protective ventilator settings and lung function recovery. Extracorporeal lung support increasingly is being applied to treat ARDS. However, conventional extracorporeal membrane oxygenation (ECMO) generally involves using large cannulae capable of carrying high flow rates. A subset of patients with ARDS has mixed hypercapnia and hypoxemia despite high-level ventilator support. In the absence of profound hypoxemia, ECCO2R may be used to reduce ventilator support requirements to lung-protective levels, while avoiding risks associated with conventional ECMO.

Percutaneous coronary intervention with the TandemHeart™ percutaneous left ventricular assist device support: Six years of experience and outcomes.

OBJECTIVES: Our study was designed to evaluate the outcomes of TandemHeart™ assistance during percutaneous coronary intervention, specifically in relationship to pre-procedural clinical and hemodynamic risk factors in patients ineligible for surgical revascularization. BACKGROUND: We have used the TandemHeart™ percutaneous left ventricular assist device during percutaneous coronary intervention (PCI) in patients for whom conventional PCI and aorto-coronary bypass would pose substantial risk owing to comorbidities and/or clinical presentations. METHODS: We retrospectively analyzed data from 626 consecutive PCIs at the Texas Heart Institute from 2005 to 2011. Among these, 74 interventions were performed with TandemHeart™ support. Mortality and morbidity were analyzed in relationship to presentation status (elective, urgent, emergent, or emergent salvage), and then we recorded outcomes and survival rates over the course of six years. RESULTS: At 30 days after PCI, survival rates were 94%, 88%, 79%, and 55% in the elective, urgent, emergent, and emergent salvage groups, respectively. Survival rates at one year were at 75% in the elective, 64% in the urgent, 52% in the emergent, and 45% in the emergent salvage groups. Survival rates at 6 years were 68% in the elective, 53% in the urgent, 31% in the emergent, and 41% in the emergent salvage groups, respectively. In elective and urgent groups, successful weaning from mechanical support was possible in all patients. In the emergent and emergent salvage groups, successful weaning from mechanical support was possible in 84% and 55% of patients, respectively. CONCLUSIONS: TandemHeart™ assisted PCI is a viable option for revascularization in cases of profound cardiogenic shock or extremely risky intervention due to complex anatomy. © 2015 Wiley Periodicals, Inc.

Use of Subclavian Extracorporeal Carbon Dioxide Removal for COVID-19 Acute Respiratory Distress Syndrome as a Bridge to Lung Transplantation.

Severe acute hypercapnia is independently associated with increased adverse effects and intensive care unit mortality in mechanically ventilated patients. During the severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic, some patients were placed on extracorporeal carbon dioxide removal support when extracorporeal membrane oxygenation (ECMO) support was at capacity or not offered. We present a patient with severe acute respiratory distress syndrome caused by COVID-19 pneumonia, who was supported with Hemolung Respiratory Assist System (ALung Technologies, Inc., LivaNova, Pittsburgh, PA) via the right subclavian vein as a bridge to lung transplantation after venovenous ECMO support. The patient survived and was discharged home.