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Severe myocardial dysfunction and added afterload from the Extra Corporeal Membrane Oxygenation (ECMO) arterial cannula may lead to significant rise in left ventricular (LV) end-diastolic and left atrial (LA) pressures. This may result in ischemia, lower likelihood of ventricular recovery and hence raise the already high mortality in this group. Various mechanical approaches have been suggested but available literature in adults is limited.
We retrospectively reviewed all patients on ECMO that underwent Percutaneous Balloon Atrial Septostomy (PBAS) for left heart decompression at our institution over 3 years. Left heart decompression based on echocardiography, pulmonary edema on chest radiograph and improvement in LA pressure, as well as mortality at 30 days were analyzed.
Six patients, (age 54±18 years; 3 males) were identified. LA pressure improved immediately post septostomy in 4 (80%) / 5 patients. Pulmonary edema improved within 24 hours in 5 (83%) patients. LV decompression on echocardiography was felt in 3 (50%) patients. Four out of six patients died due to multiorgan failure.
Percutaneous Atrial Septostomy appears to decompress left heart in patients on ECMO and profound shock. However, due to multi-organ involvement, mortality in this critically sick group remains high.
|Patient||Etiology||Cardiac arrest||Time from ECMO to Septostomy (hours)||Left atrial pressure (mmHg) Pre / Post Septostomy||Pulmonary edema on radiograph at 24 hours||LV decompression on echo||Survival||Time from septostomy to death||Cause of death|
|1||LMCA MI||No||72||15 / 9||Improved||No||No||Day 17||Multiorgan failure|
|2||LMCA MI||Yes||456||20 / 20||Improved||No||Yes||--||Left ventricular assist device|
|3||LMCA dissection||Yes||72||Not available||Improved||Yes||No||Day 9||Multiorgan failure, multiple ischemic stroke|
|4||Influenza||No||30||32 / 24||Improved||Yes||Yes||--||Discharged on day 31|
|5||ARDS||Yes||20||60 /30||Not Improved||No||No||8 hours||Multiorgan failure|
|6||MI||Yes||240||16 / 9||Improved||Yes||No||52 hours||Multiorgan failure|
LMCA = Left Main Coronary Artery, MI = Myocardial Infarction, ARDS = Acute Respiratory Distress Syndrome.