Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation

The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients

“…Recommendations for the Conduct of ECMO Support in Pediatric Heart Transplant Recipients: 115,116 Class IIa:…”

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

“…Cardiac catheterization can be performed safely in young patients on ECMO, with a fairly low risk of major complications (most commonly bleeding and myocardial perforation), ranging from 3% to 7% in two medium-sized series (3,4). Percutaneous decompression of the left heart on ECMO has been accomplished in pediatric and young adult patients through a variety of techniques including balloon atrial septostomy under transthoracic (5) and transesophageal (6) echocardiographic guidance, combined blade and balloon atrial septostomy under fluoroscopic guidance (7), and both transseptal (8) and transaortic (9) left ventricular sheath placement. Ward et al (10) described a single case of transesophageal echo-guided transseptal left atrial decompression via a sheath connected in-line into the venous return limb of the ECMO circuit in a 16-month-old child.…”

Mechanical support of the pediatric cardiac patient

“…This, in turn, may lead to an increase in left ventricular end diastolic pressure, followed by pulmonary edema. 17 …”

“…Hearts that are capable of ejecting or have septal defects typically do not require venting, although venting may offer theoretical benefits such as decreased oxygen consumption and possibly improved myocardial blood flow. The patients who are most prone to requiring left ventricular venting appear to be those with a dilated cardiomyopathy or myocarditis 17. Regardless of the underlying pathophysiology, any evidence of pulmonary edema or left atrial dilation should lead to consideration of venting the systemic ventricle.…”