A 53 year old female without significant past medical history developed severe viral pneumonia, with rapid, progressive deterioration in her respiratory status.
She developed ARDS and mechanical ventilatory management using ARDS protocol were unable to maintain adequate oxygenation.
As a result, bedside VV-ECMO was planned.
Transesophageal echocardiography (TEE) was performed to visualize proper positioning of the guidewire and cannula.
Using the Seldinger technique, the right internal jugular vein was accessed and a guide wire was placed.
Placement of the guidewire into the IVC proved difficult due to repeated migration of the guidewire into the right ventricle.
After multiple attempts, the guidewire was visualized to course properly from the SVC to the IVC.
After a bolus dose of 5000 units of intravenous heparin was given, the right internal jugular venous access site was dilated.
Just as the final dilatation was completed and upon dilator exchange with simultaneous advancement of the 23 French Avalon cannula, TEE lost visualization of the guidewire.
Multiple premature ventricular beats were noted and immediately, a new, rapidly enlarging pericardial effusion was detected (Figure ​(Figure2).2).
Emergent preparations were made for bedside surgical decompression of the pericardial space.
Quickly the patient lost blood pressure from acute cardiac tamponade.
The Avalon cannula was immediately clamped at the end but not removed.
A emergent subxiphoid pericardial window was performed, resulting in drainage of venous blood and restoration of blood pressure.
Transfusion was initiated and the patient was emergently transported to the operating room for surgical exploration.
The Avalon cannula was found to have perforated the apex of the right ventricle.
The injury was repaired primarily and the Avalon cannula was repositioned toward the IVC again by TEE with additional direct manipulation.
VV-ECMO was initiated and the oxygenation improved.
Due to excessive coagulopathies, the sternum was left open but was closed on postoperative day 2.
From that point, she remained free from any cardiac or infectious complications and her pulmonary condition slowly improved.
She was successfully weaned from VV-ECMO on postoperative day 9 and was discharged home on postoperative day 24 without the need for home oxygen.
She regained full physical functions at home and recovered normal pulmonary function by 3 months following discharge from the hospital.