PMC8578850_01
(A) Massive air leak syndrome with pneumomediastinum, bilateral pneumothorax, and subcutaneous emphysema. (B) GW (arrows) displayed straight from the SVC to IVC; the red lines show how a discontinuous hyperechoic image can help in ruling out looping; right atrium (RA), Eustachian valve (EV). (C) Absence of looping or GW malposition in the right ventricle (RV) is demonstrated in four-chamber MEV; tricuspid valve (TV), mitral valve (MV). (D) Mid-esophageal bicaval view showing the correct position of the cannula (C) with the infusion port (IP) in the middle of the right atrium; infusion jet (IJ). (E) Four-chamber MEV confirming the direction of the IJ toward the tricuspid valve. (F) Chest X-ray demonstrating the correct position of the cannula; the green line measures the tip-to-IP distance (9.4 cm).
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ARDS exacerbated (PaO2/FiO2 95) with massive ALS (Figure 1A), a common complication of COVID-19 with protracted course. ALS developed at unmodified MV settings, requiring bilateral chest drain placement. To minimize the risk of viral contamination, BCDL ECMO cannulation was performed at the bedside, according to a technique previously described (Figure 1). To facilitate the advancement of the GW from the superior vena cava (SVC) to the inferior vena cava (IVC), the tip was bent in a hockey stick fashion, with the same angulation as the one between the two vessels. The position of the GW and its straight and uncoiled progression were checked after each dilation on bicaval and four-chambers MEVs, excluding any looping or displacement in the right ventricle (Figures 1B,C). The absence of loops is assured if the GW generates a continuous hyperechoic image from the SVC to the IVC (Figure 1B). This is of paramount importance to prevent cardiac perforation during dilators and cannula advancement. TEE allowed the fine adjustment of the infusion port in front of the tricuspid valve, demonstrating the correct trajectory of the inlet jet (Figures 1D,E). Measure taking on echo and chest X-ray images allows a double check of the location of the infusion port into the right atrium (Figure 1F).