Cardiac Decompression on Extracorporeal Life Support

Abstract

Extracorporeal life support is a worldwide expanding technology for patients in critical cardiogenic shock. The device is usually attached to the femoral vessels using percutaneous techniques. Despite sufficient extracorporeal circulatory support, an unclear number of patients develop high end-diastolic pressures leading to left ventricular distension and pulmonary edema, and ventricular thrombus formation may evolve. This article discusses the strategies to prevent ventricular distension by conservative, interventional, and surgical means, also illustrated by case presentations.

Transseptal balloon atrial septostomy for decompression of the left atrium during extracorporeal membrane oxygenation support as a “bridge to transplantation” in dilated cardiomyopathy

“…Various methods, both surgical and nonsurgical, have been applied to decompress the left atrium or ventricle [4–8]. We describe the use of balloon dilatation of the atrial septum performed at the hybrid catheterization laboratory using transesophageal echocardiographic guidance to effectively decompress the left atrium.…”

Monitoring during extracorporeal membrane oxygenation

“…Pulmonary edema secondary to left ventricular distension may subside by venting of the left atrium [37][38][39][40]. Adding a veno-venous component for a veno-venous arterial configuration may be indicated in case of concomitant pulmonary disease.…”

“…Some authors have suggested the concomitant use of intra-aortic balloon pump or microaxial pump to decrease the LV afterload [44][45][46][47][48][49]. When severe pulmonary edema is present, left atrial venting has been proven effective to alleviate pulmonary congestion [37][38][39][40]45,50].…”

What is extracorporeal cardiopulmonary resuscitation?

“…From one side, the need for restoration of systemic perfusion pushes toward higher flows but, on the other, the risk of left ventricular (LV) distension, endoventricular stasis and pulmonary oedema frightens the clinician (26,27). To the best of our knowledge, even if no studies have compared different strategies of ECMO flow regulation after cardiac arrest (hyperflow, normal flow, partial assistance), we strongly advise that the opportunity of setting the pump flow to values allowing for a rapid lactate clearance, restoration of urine output, resolution of metabolic acidosis should be carefully considered (28).…”