Percutaneous Left Ventricle Unloading During Venoarterial Extracorporeal Membrane Oxygenation

To the Editor: We read with great interest the report by de Pommereau et al.1 recently published in the ASAIO Journal. The issue of left ventricular (LV) distention during venoarterial extracorporeal membrane oxygenation (VA-ECMO) is crucial as it markedly impacts on patients’ weanability and, ultimately, outcome. Numerous techniques have been described to prevent and reduce its occurrence, each with advantages and limitations,2–4 and percutaneous left-heart decompression via the pulmonary artery has a very intriguing pathophysiological rationale, allowing for retrograde unloading of the LV. This technique presents with some advantages. First, it is performed at the bedside with a completely percutaneous approach. Second, the amount of blood drained is related to the flow in the pulmonary artery; hence, an increase in right ventricular ejection will result in an augmented drainage. Last, the pulmonary artery cannula can be used as a return cannula for temporary percutaneous right ventricular support.5 We originally described this technique in the ASAIO Journal in 2011,6 and subsequently used this approach in most of our patients who needed LV decompression, with excellent results in terms of reduction in LV filling pressure and pulmonary congestion (Figure 1 reports changes in pulmonary capillary wedge pressure [PCWP] in the first 11 patients treated with this technique at our Institution, unpublished data). No complications occurred in the patients we treated so far.Figure 1.: Pulmonary capillary wedge pressure (PCWP) before (pre-drainage) and after (post-drainage) in 11 venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients.We believe that this approach can be safely used in VA-ECMO patients requiring LV decompression and constitutes a valuable additional tool in the armamentarium of patient care in this particular population.