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Lessons From ECMO: Amy’s Story

Amy Yamaguchi Was 36 Weeks Pregnant With Her First Baby When She Contracted COVID-19. What Happened Next Is a COVID-19 Horror Story, but Also a Story of Modern Medicine and a Lot of Hope.

Before there was a COVID-19 vaccine, there was Amy Yamaguchi, a 34-year-old first-time-expectant mother.

Throughout her pregnancy in 2020, Yamaguchi was diligent about masking, physical distancing and limiting her exposure to people and places. But in December of 2020, the virus nonetheless found its way to her pregnant body. What happened next is a COVID-19 horror story—one filled with life support, lung transplantation and a stroke—but also filled with medical breakthroughs that brought about a happy ending.

“This experience has completely changed me,” said Yamaguchi, from Seal Beach. “I now understand bad things happen to really good people—not because we’ve done something wrong, but because that’s life. I’ve learned to give myself permission for these hardships and move past them.”

For her Cedars-Sinai medical team, Yamaguchi’s case is a dramatic illustration of the powers of a powerful technology—extracorporeal membrane oxygenation, or ECMO—that continues to be used in new ways throughout the pandemic. As the American Heart Association Scientific Sessions get underway, the advances in ECMO during COVID-19 is sure to be a topic of conversation among attendees.

“In the early days of the COVID-19 pandemic, we debated the role of ECMO,” said Michael Nurok, MD, PhD, medical director of the Cardiac Surgery Intensive Care Unit in the Smidt Heart Institute and a key member of Yamaguchi’s care team. “We knew that ECMO for respiratory failure could be lifesaving. The challenge was that our units were full of patients and ECMO was far more resource intensive than other forms of respiratory support including mechanical ventilation. There were a lot of unknowns.”

Ultimately, Nurok and team decided they had an obligation to provide ECMO in well-selected patients like Yamaguchi.

A Life-Changing Diagnosis

Yamaguchi was 36 weeks pregnant when she was diagnosed with COVID-19, just days before the COVID-19 vaccine became available to health professionals. Within days, her oxygen levels dropped so low her husband, Daniel Levin, had to rush Yamaguchi to a nearby community hospital in Orange County. Due to COVID-19 restrictions, Levin couldn’t accompany them past the door.

Yamaguchi was quickly diagnosed with COVID-19 pneumonia. Doctors said they needed to deliver her daughter via emergency cesarean section to free space for Yamaguchi’s lungs. So, two days later, on Dec. 7, 2020, Yamaguchi and Levin’s daughter, Maren Marie Levin, was born.

Shortly after, Yamaguchi’s Orange County care team knew she needed the higher level of care available at an academic medical center and transferred her to Cedars-Sinai. Yamaguchi was airlifted to Cedars-Sinai without ever having held her baby, and Maren was sent home with Levin.

From Motherhood to Life Support

Upon arrival at Cedars-Sinai’s Intensive Care Unit, Yamaguchi was immediately placed on ECMO.

“Amy had exhausted all of the options her local hospital could offer,” said Dominic Emerson, MD, associate surgical director of Heart Transplant and Mechanical Circulatory Support and Yamaguchi’s lead physician. “Amy was young, completely healthy and active outside of her COVID-19 diagnosis and had just delivered a baby. We wanted to do everything we could for her.”

Emerson said Yamaguchi was deathly sick when she arrived at the medical center.

“Her lungs were not functioning well, and she was requiring a tremendous amount of support from the ventilator,” said Emerson, also the surgical co-director of the Cardiac Surgery Intensive Care Unit in the Smidt Heart Institute. “That is unfortunately the way we see most of our transfers for ECMO—these patients are right on the edge of not surviving.”


COVID-19 Changes ECMO Practices

Before COVID-19, ECMO was used as a last-ditch effort for patients and often called a “Hail Mary pass” by experts. However, the technology has been employed so often during the global pandemic that Cedars-Sinai physicians have learned new, effective ways to utilize the machine and save lives.

While on ECMO, a patient’s blood is pumped out of their body, put through an artificial lung, then pumped back into the patient’s body. The machine—similar to a heart-lung bypass machine—has been around for several decades, although its use for lung failure has increased significantly in the past decade.

“We used to reserve ECMO for the very sickest patients, those with no other options,” said Pedro Catarino, MD, director of Aortic Surgery in the Department of Cardiac Surgery and one of Yamaguchi’s transplant surgeons. “However, we now know that in carefully selected patients, we can use ECMO as a bridge to lung transplantation, or even use ECMO as a chance for a patient’s body to heal their own lungs.”

In addition to better understanding who is an ideal candidate for ECMO, Smidt Heart Institute physicians and surgeons have learned other key lessons in how best to treat patients with this complex therapy.

“If you asked me 18 months ago if we could manage patients on ECMO without sedation, I would have said it was nearly impossible,” said Nurok, also a professor of Cardiac Surgery. “The paradigm shifted to now, treat pain aggressively but only sedate patients when necessary.”

If less sedated, Nurok says, these patients can mobilize more easily.

“If patients are able to stand and eventually walk, their recovery—whether eventually that means lung recovery and removal of ECMO or a transplant—goes significantly more smoothly.”

Another key lesson learned is the value in removing breathing tubes. Doing so, Nurok said, is yet another opportunity for a patient to become mobilized and actively engaged in their recovery.

However, the challenge in keeping patients more alert, Nurok said, is managing discomfort and anxiety—both for patients and their medical teams. That’s because most patients on ECMO are air-hungry, short of breath, and often are too weak to mobilize during the initial course of their disease.

When they start ECMO, Nurok said, patients have often been deeply sedated for days. They are confused, their sleep-wake cycles are disturbed, they likely drift in and out of consciousness.

As medical professionals lighten the amount of sedation they receive, patients become delirious and agitated very easily. When a patient becomes severely agitated or anxious, the care team’s reflex is to sedate them again; it’s a reflex that Nurok said medical personnel had to suppress and unlearn.

“We had to get patients and clinicians on the same page, helping everyone understand that creating the conditions whereby the breathing tube could be removed required less use of sedatives and that this would be difficult for a day or so,” said Nurok. “But if we worked together with the patient toward this goal, the outcome would be better.”

Between March 2020 and Oct. 31, 2021, Cedars-Sinai has placed 54 COVID-19 patients on ECMO.

From Life Support to Lung Transplantation

Before COVID-19, Smidt Heart Institute experts used ECMO for much shorter time periods—in 2019 treating just 98 patients with the therapy, usually for a couple of days to two weeks.

In contrast, Yamaguchi was on ECMO for a total of 119 days, an unpreceded length of time pre-COVID, but a somewhat new normal for patients battling the virus. Although the initial hope was for Yamaguchi’s lungs to recover, that hope diminished with each passing day.

“Her lungs went into this phase of fibrosis, where the lung starts to scar, and there’s no way for your body to recover from that,” said Emerson. “Despite giving Amy time and supporting her with every available treatment and therapy, we had to accept that her lungs would never be able to heal enough to support her body.”

Because of this, Yamaguchi’s care team and family knew a lung transplant was her only hope at survival.

“It was devastating to hear Amy needed a lung transplant, but I was always confident in her medical team and always confident in Amy,” said Levin, a 35-year-old schoolteacher. “Amy is very determined, strong-willed and wants to be in charge. I knew she would make it through the transplant and make it out of the hospital alive.”

Yamaguchi was Cedars-Sinai’s first COVID-19 lung transplantation, but not the last.

Between Jan. 1, 2021 and Nov. 8, 2021, Cedars-Sinai completed 52 lung transplants, eight of which were COVID-19-related transplants. Prior to 2021, Cedars-Sinai cardiothoracic surgeons did not perform lung transplants in patients on ECMO, considering them too high risk.

Yamaguchi’s operation lasted nine hours and was met with complications, the most challenging being a series of ministrokes, which gravely impacted Yamaguchi’s memory as well as her mobility on the left side of her body.

“Complications like these are not limited to Amy,” said Emerson. “COVID-19 transplant cases are far more difficult because there is extreme inflammation in the chest and surrounding the lungs, and an abnormally high tendency to form blood clots. These patients are also sicker than most any other patient in the hospital, so the already high-risk surgery becomes increasingly high risk.”

Although the journey to transplantation was long and difficult for Yamaguchi, she made it, and for the first time in months, she and her family had newfound hope.

Missing Memories

Yamaguchi spent more than five months at Cedars-Sinai, most of which she has no recollection. In fact, when she woke up after her transplant, the new mother realized she had no memories from the past five years.

“I asked my mother who the man was that was always hanging out in my room,” said Yamaguchi. “She told me it was my husband, Daniel. I had no memory of getting married, being pregnant or even having Maren. The last five years of my life were gone. It was overwhelming.”

Some memories returned quickly to Yamaguchi, but many are still missing.

“My memory is one of the biggest hurdles I’m still facing,” said Yamaguchi. “But as soon as I learned about Maren, that is what pushed me through my recovery. I just wanted to meet her and hold her.”

Meeting Maren

Shortly before Yamaguchi left Cedars-Sinai to recover from her stroke at a rehabilitation center, she finally had the reunion she was yearning for: meeting and holding Maren, who was then five months old.

Although Yamaguchi feared Maren wouldn’t know her, the reunion went off without a hitch—or a dry eye.

“The doctors and nurses at Cedars-Sinai told me, ‘Maren will remember you; she has known you the longest,’” said Yamaguchi. “Danny brought her to me and placed her in my lap, and it was overwhelming—in a good sense. Just like what it would have been if I had a normal birth experience. It was so good.”

The bond between mother and daughter continued to grow after Yamaguchi finally went home on Aug. 3, 2021—more than 34 weeks after first arriving at her local hospital.

Today, Yamaguchi looks forward to regaining her strength and memory and resuming a more “normal” life for a 35-year-old mother.

“I want to get to the point where I can pick Maren up, then stand up with her,” said Yamaguchi. “I want to get down on the floor with her a little more naturally, without feeling so scared. Everything else is moving along.”

Although the Smidt Heart Institute has performed seven additional COVID-19 lung transplantations since Yamaguchi’s, she has left a profound impact on the team.

“Amy was our first ECMO bridge to transplant, and she also was our first post-COVID-19 pneumonia transplant,” said Catarino. “She’s a very special person and patient. It’s remarkable to see the progress she has made, knowing all she has been through.”

Reinaldo Rampolla, MD, medical director of the Lung Transplant Program, said Yamaguchi’s progress is nothing short of miraculous.

“Before Amy’s lung transplant, she had no days left,” said Rampolla, who stayed in the operating room during Yamaguchi’s transplant and now is the primary doctor overseeing her post-transplant recovery. “Today, because of the exceptional care she received at Cedars-Sinai, Amy has countless days left to live a full and rewarding life. She is a ray of sunshine, and her story will always stay with me.”

Read more from the Cedars-Sinai Blog: Being Patient: The Delicate Timing of Organ Transplantation