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Use of Percutaneous Atrioseptotosmy for Left Heart Decompression During Veno‐Arterial Extracorporeal Membrane Oxygenation Support: An Observational Study

Background Left ventricular overload is frequent under veno‐arterial extracorporeal membrane oxygenation, which is associated with a worsening of the prognosis of these patients. Several left heart decompression (LHD) techniques exist. However, there is no consensus on their timing and type. We aimed to describe characteristics and outcomes of patients undergoing LHD and to compare percutaneous atrioseptostomy (PA) to other LHD techniques. Methods and Results Retrospective analysis was conducted of consecutive and prospectively collected patients supported by veno‐arterial extracorporeal membrane oxygenation for refractory cardiac arrest or cardiogenic shock between January 2015 and April 2018, with a 90‐day follow‐up in our tertiary center. Patients were divided according to the presence of LHD, and then according to its type (PA versus others). Thirty‐nine percent (n=63) of our patients (n=163) required an LHD. Patients with LHD had lower left ventricular ejection fraction, more ischemic cardiomyopathy, and no drug intoxication‐associated cardiogenic shock. PA was frequently used for LHD (41% of first‐line and 57% of second‐line LHD). PA appears safe and fast to realize (6.3 [interquartile range, 5.8–10] minutes) under fluoroscopic and echocardiographic guidance, with no acute complications. PA was associated with fewer neurological complications (12% versus 38%, P=0.02), no need to insert a second LHD (0% versus 19%, P=0.04), and higher 90‐day survival compared with other techniques (42% versus 19%, log‐rank test P=0.02), despite more sepsis (96% versus 73%, P=0.02) and blood transfusions (13.5% versus 7%, P=0.01). Multivariate analysis confirms the association between PA and 90‐day survival (hazard ratio, 2.53 [1.18–5.45], P=0.019). Conclusions LHD was frequently used for patients supported with veno‐arterial extracorporeal membrane oxygenation, especially in cases of ischemic cardiomyopathy and low left ventricular ejection fraction. PA seems to be a safe and efficient LHD technique associated with greater mid‐term survival justifying the pursuit of research on this topic.


VA-ECMO management protocol
VA-ECMO indications and management were based on our local protocol and available guidelines through a multidisciplinary team including cardiologists, intensivists, and cardiac surgeons. Briefly, VA-ECMO was discussed for RCS defined by persisting mismatch between oxygen supplies and tissue needs due to a pump dysfunction despite inotrope and/or vasopressor perfusion. In case of RCA, VA-ECMO implantation was discussed only for selected patients (≤ 70 yo, witnessed cardiac arrest, BMI < 40 kg/m², end-tidal CO2 > 10 mmHg, pH level > 6.9 and lactatemia < 25 mmol/L at ICU arrival). Contra-indications to VA-ECMO were common: age > 80 years; anticoagulation contraindication; severe peripheral artery disease; significant aortic regurgitation; life expectancy less than 5 years due to associated chronic or acute illness and severe post anoxic coma. Anticipated directives were also taken into consideration.
VA-ECMO was initiated under general anesthesia by femoral approach thanks to a modified Seldinger technique. The circuit used includes a venous inflow cannula (23 to 29 Fr) inserted up to the inferior vena cavaright atrium junction, a SORIN® centrifuge pump with a D905® oxygenator (or a MAQUET® centrifuge pump with a QUADROX® oxygenator), and an arterial outflow cannula (19 to 21 Fr) inserted up to the common iliac artery with systemic insertion of a reperfusion cannula (7 Fr) for the ipsilateral superficial femoral artery. The initial output is adjusted to the theoretical cardiac output (70/mL/kg/min) then to a target MAP ≥ 65 mmHg (after volume loading and vasopressors, if necessary). Inotrope support with dobutamine could be continued to maintain an aortic valve opening. Curative anticoagulation was started by intravenous unfractionated heparin for a target anti-Xa level between 0.2 and 0.4 IU/mL. The decision to wean the patient from VA-ECMO depends on a set of clinic-biological and ultrasound criteria assessed by daily weaning trial at a minimum VA-ECMO output of 1.5-2 L/min.

Characteristics of left heart decompression used (9)
The IABP (AutoCAT 2 Wave TELEFLEX®) is implanted in the descending aorta then connected to an electrocardiogram in order to inflate the balloon with helium during protodiastole and deflate it during telediastole, thereby reducing the LV afterload while increasing diastolic blood pressure (DBP) and thus coronary and cerebral perfusion.
The micro-axial flow pump Impella (Abiomed, Danvers, MA, USA) is a catheter-based LV assist device which is inserted into the LV cavity via arterial access (axillary or subclavian acess in case of Impella 5.0, and femoral access in case of Impella CP). From that position, it actively drains blood from the LV and propels it into the proximal ascending aorta, thereby decreasing LV preload and increasing cardiac output.
Percutaneous atrioseptostomy (PA) involves creating a left-right shunt through perforation of the interatrial septum after femoral vein catheterization. PA was performed under fluoroscopic guidance in the hemodynamical or electrophysiological laboratories, with the help of trans-oesophageal echocardiography when needed. After femoral venous catheterization, transseptal puncture was performed according to usual techniques (10) with a SLO sheath (St Jude Medical ™) and Brokenbrough needle, under common fluoroscopic landmarks and/or pressure monitoring. Of note that transseptal puncture was sometimes especially tricky in this situation, due to the presence of the ECMO venous canula, anticoagulation and dilated/distorted cardiac anatomy. Then an aortic valvuloplasty balloon (diameter 10 to 18 mm) was mounted over a 0.32 mm guidewire positioned in the left superior pulmonary vein. The sheath was then removed into the right atrium and the balloon was inflated at the level of the transseptal puncture in order to create an inter-atrial communication and thus maintain a significant left-right shunt (11).
The surgical decompression is the addition of a left intraventricular cannula to the venous circuit of the VA-ECMO by surgical approach: a transvalvular aortic cannula by a subclavian artery or axillary approaches , or directly through the LV by transapical thoracotomy or sternotomy.
The different LHD techniques were implemented and checked under x-ray and/or ultrasound guidance (transesophageal echo (TEE) or transthoracic echo (TTE)).