Atrial septostomy and left ventricular venting in patients requiring VA-ECMO

Abstract Background Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) provides comprehensive pulmonary and circulatory support in refractory cardiogenic shock (CS). Retrograde flow from VA-ECMO is believed to increase left ventricular (LV) afterload. We investigate whether balloon atrial septostomy (BAS) provides effective LV venting in addition to LV unloading in this setting. Methods We conducted a retrospective analysis of consecutive adult patients in CS who underwent VA-ECMO initiation with concomitant BAS for LV venting between November 2019 and April 2024. Failure of LV venting was defined as a composite outcome including escalation to intra-aortic balloon pump (IABP) or Impella, CVA attributable to VA-ECMO, echocardiographic evidence of LV thrombus, aortic root thrombus, LV distension, spontaneous echo contrast ("smoke") in the LV/aortic root or worsening pulmonary edema on chest x-ray. Results Twenty-eight patients underwent VA-ECMO with atrial septostomy. Baseline characteristics are described in the central illustration. LV venting failure occurred in 54% of patients, mostly driven by evidence of pulmonary edema occurring in 39.3% of patients. 30-day mortality in our cohort was 43%. Conclusion In select patients, BAS may provide effective LV unloading but warrants a high degree of surveillance to ensure adequate LV venting.Central Illustration