ID:104 FC-D10-6 Video-Assisted Thoracoscopic Mediastinal Drainage as Salvage Therapy for Tension Pneumomediastinum during VV-ECMO

Background: Tension pneumomediastinum is a rare, life-threatening complication of ARDS. VV-ECMO–supported conservative management may be attempted; however, persistent tension physiology requires surgical decompression, and the optimal approach remains unclear. We report two cases in which VATS-guided mediastinal drainage improved tension pneumomediastinum during VV-ECMO. Clinical Course: Case 1: A 68-year-old man with influenza-associated ARDS developed pneumomediastinum. VV-ECMO was initiated on day 9 for refractory hypoxemia. Pneumomediastinum progressed on day 11. Bedside mediastinal drainage was attempted with limited effect; therefore, VATS mediastinal incision and drainage was performed. Pneumomediastinum improved by day 14, and VV-ECMO was weaned on day 21. Case 2: A 67-year-old man with COVID-19–associated ARDS required VV-ECMO from day 1. Pneumomediastinum developed on day 8 with hypotension. Bedside mediastinal drainage was attempted with limited effect; therefore, VATS mediastinal incision and drainage was performed on day 14. Pneumomediastinum improved by day 20, and VV-ECMO was weaned on day 23. Discussion: VATS mediastinal drainage enabled prompt VV-ECMO weaning without major complications in both cases. However, no established treatment exists for refractory pneumomediastinum that fails to improve despite VV-ECMO and/or limited bedside drainage. These cases suggest that VATS mediastinal drainage is a feasible salvage option and may reduce bleeding and postoperative complications. Conclusion: VATS mediastinal drainage may be an effective salvage strategy for refractory pneumomediastinum that persists despite VV-ECMO.