Decompression of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit*

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Abstract
When extracorporeal membrane oxygenation (ECMO) is used in the setting of severe myocardial dysfunction, left ventricular end-diastolic and left atrial pressure can rise to extremely high levels. Decompression of the left atrium in this setting is essential for resolution of pulmonary edema and recovery of left ventricular function. We sought to evaluate whether adequate left atrial decompression can be achieved via percutaneous placement of a transseptal left atrial drain incorporated in the ECMO venous circuit. Retrospective case series. Tertiary care center pediatric intensive care unit and cardiac catheterization laboratory. Seven patients (age 8 months to 28 yrs) with cardiac failure on venoarterial ECMO with left atrial hypertension. All patients underwent left atrial decompression with transseptal puncture and placement of a drain (8- to 15-Fr) incorporated into the ECMO venous circuit. Catheterization and ECMO records and echocardiograms were reviewed, as were the clinical course and outcome for each patient. The median time from ECMO cannulation to left atrial decompression was 11 hrs. Average initial left atrial pressure was 31 mm Hg. Successful drain placement was achieved in seven patients with no major procedural complications. Echocardiographic improvement in left atrial dilation was achieved in five patients (71%). Inability to decompress the left atrium was fatal in two patients. Four patients were decannulated (57%), and three survived to hospital discharge (43%). Larger sheath size and higher flow rate correlated with a greater likelihood of success. Adequate decompression of the left atrium can be achieved by transseptal placement of a left atrial drain incorporated into the ECMO circuit. This technique represents a reasonable alternative to blade or balloon atrial septostomy for patients requiring left atrial decompression.

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