Spontaneous hemothorax in 4 COVID-19 ARDS patients on
VV-ECMO revealing pulmonary artery aneurysms
by Cyrielle Desnos, Samia Boussouar, Guillaume Hekimian,
Alban Redheuil and Alain Combes
Critical Care volume 24,
Article number: 638 (2020)
COVID-19 pneumonia is a cause of severe ARDS. Its
pathophysiology involves endothelial dysfunction and angiogenesis related to
ACE-2 receptor, the host-cell receptor for SARS-CoV-2, expressed by endothelial
cells, which may lead to thrombosis or hemorrhage [1].
This case series describes the presentation of COVID-19
patients who had unusual spontaneous hemothorax while on veno-venous extra
corporeal membrane oxygenation (VV-ECMO) for severe ARDS. In accordance with
French legislation, only non-opposition of patient’s surrogate for utilization
of the deidentified data was obtained. The ICU database was registered with the
national data protection authority (CNIL 1950673). From February to September
2020, 62 patients with confirmed COVID-19-related severe ARDS requiring VV-ECMO
were transferred and treated in our tertiary care ICU, of whom 4 had
spontaneous hemothorax.
Ages were 33, 63, 48 and 46 years; 2 patients were
women. None of them had pulmonary embolism on previous CT angiography, and they
had received continuous infusion of unfractionated heparin at high preventive
dose according to international expert guidelines [2].
They were on VV-ECMO for 3, 9, 22 and 28 days at the time of the
hemothorax onset. In all four patients, hemothorax was revealed by shock, both
hemorrhagic and obstructive by compression of the mediastinum, requiring high
doses of catecholamine and massive packed red blood cells transfusion. One
patient experienced cardiac arrest shortly after shock onset, resuscitated
after chest drainage. On chest CT scan, vascular lung abnormalities were very
similar in the 4 patients, including peripheral medium and small pulmonary
artery branches aneurysms, one of them also having renal and diaphragmatic
artery aneurysms (Fig. 1).
Three of the patients underwent salvage radioembolization, one of them survived
to this episode without relapse, and hemothorax was fatal for the 3 others…
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