Fatal hemothorax following complicated VV-ECMO cannulation in an anticoagulated patient with severe COVID-19 pneumonia.

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is a lifesaving procedure for patients with acute respiratory distress syndrome (ARDS) due to severe coronavirus disease (COVID-19) pneumonia. COVID-19 infection is a risk factor for the development of coagulopathy and anticoagulant treatment is recommended. Moreover, anticoagulant therapy is often used to prevent circulatory coagulopathy during ECMO therapy. A man on dual antiplatelet therapy was hospitalized with severe COVID-19 pneumonia and treated with standard therapy. Apixaban was administered for a suspected coagulopathy. His medical condition deteriorated, and ECMO therapy was initiated for life support. During cannulation of a return cannula in the right internal jugular vein (RIJV), the guidewire became malpositioned. The patient developed acute onset of hypotension and bradycardia, which progressed to cardiac arrest. Ultrasonography identified a right hemothorax, and a chest tube was inserted. The patient died despite attempts at resuscitation. Postmortem computed tomography showed a large hemothorax and a guidewire penetrating the RIJV into the right pleural cavity. An autopsy was performed two days post-mortem. The autopsy found an injured RIJV, a hematoma around it, and a hemothorax. Histology of the lung revealed inflammatory cell infiltration and fibrosis, consistent with ARDS. The direct cause of death was hemorrhagic shock and respiratory failure due to a large hemothorax resulting from perforation of the RIJV during VV-ECMO catheter insertion. This case highlights the necessity of a safety protocol during ECMO insertion and assessment of bleeding risk in patients with COVID-19 receiving anticoagulant therapy.