Key result
Balloon atrial septostomy for VA-ECMO unloading yields ~54% LV venting failure, driven by pulmonary edema.
Why the study?
Peripheral VA-ECMO increases LV afterload leading to LV distension and pulmonary edema, and the durability of balloon atrial septostomy for LV venting remains uncertain.
Does balloon atrial septostomy (BAS) provide durable LV venting in adults requiring peripheral VA-ECMO for cardiogenic shock?
Cohort (n=28)
No
Does balloon atrial septostomy (BAS) provide durable LV venting in adults requiring peripheral VA-ECMO for cardiogenic shock?
While balloon atrial septostomy effectively decompresses the left atrium during peripheral VA-ECMO, over half of patients still experience LV venting failure, suggesting it may not be sufficiently durable for all patients.
BAS lowers left atrial pressure in VA-ECMO but venting failure remains frequent; hypothesis-generating, prospective trials needed before adoption.
BACKGROUND: Peripheral venoarterial (VA)-extracorporeal membrane oxygenation (ECMO) increases left ventricular (LV) afterload, and therefore the risk of LV distension, pulmonary edema, and cardiac stasis. Balloon atrial septostomy (BAS) provides atrial-level unloading, but the durability of LV venting remains uncertain. OBJECTIVES: This study aimed to evaluate the clinical effectiveness of BAS for LV venting in patients requiring peripheral VA-ECMO for cardiogenic shock (CS). METHODS: The authors conducted a retrospective study of consecutive adults with CS supported with peripheral VA-ECMO who underwent BAS for LV unloading at an academic center (2019-2024). The primary endpoint was LV venting failure, a composite of pulmonary edema, LV distension, spontaneous echocardiographic contrast, LV or aortic root thrombus, stroke due to ECMO, or escalation to additional mechanical support. RESULTS: A total of 28 patients were included in the study. BAS resulted in a significant reduction in mean left atrial pressure (20.5-13.5 mm Hg; P < 0.001). Durable LV venting was achieved in a subset of patients; however, LV venting failure occurred in 53.6%, driven primarily by pulmonary edema. Pulse-pressure trajectories differed according to eventual LV venting-failure status (interaction P = 0.018). Model-estimated pulse pressure was higher at 48 hours (P = 0.010) and 72 hours (P = 0.031) among patients who ultimately did not experience venting failure. CONCLUSIONS: Among patients receiving peripheral VA-ECMO for CS, BAS achieves atrial-level decompression and may provide durable LV venting in select patients, although venting failure remains common. Observed arterial pulse-pressure trajectories differed according to eventual LV venting failure status.
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Kapoor et al. (2026) conducted a cohort in Cardiogenic shock requiring peripheral VA-ECMO (n=28). Balloon atrial septostomy was evaluated on Left ventricular venting failure, a composite of pulmonary edema, LV distension, spontaneous echocardiographic contrast, LV or aortic root thrombus, stroke due to ECMO, or escalation to additional mechanical support. Balloon atrial septostomy for LV unloading during peripheral VA-ECMO for cardiogenic shock resulted in a 53.6% incidence of LV venting failure, driven primarily by pulmonary edema.
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