Cardiovascular perforation during placement of an Avalon Elite® Bicaval dual lumen ECMO cannula in a newborn

Proper functioning of the Avalon Elite® bicaval dual lumen ECMO cannula (Maquet Cardiovascular, Wayne, NJ, USA) requires precise placement of the distal draining port within the lumen of the inferior vena cava (IVC). In order to advance the cannula to the correct position, a 0.038" guidewire is placed into the IVC under echocardiographic or fluoroscopic guidance. We report a case of perforation of the intrapericardiac section of the IVC by the guidewire in a neonate, not detected at the time of placement, resulting in cardiac tamponade and death. We recommend routine echocardiographic surveillance after placement of Avalon Elite® cannulas to rule out hemopericardium.