title: Decompression of the left atrium during extracorporeal membrane oxygenation using a transseptal cannula incorporated into the circuit.
abstract: OBJECTIVE
  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.
  
  
  METHODS
  Retrospective case series.
  
  
  METHODS
  Tertiary care center pediatric intensive care unit and cardiac catheterization laboratory.
  
  
  METHODS
  Seven patients (age 8 months to 28 yrs) with cardiac failure on venoarterial ECMO with left atrial hypertension.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA.
authors.forename: Ranjit M
authors.initials: RM
authors.lastname: Aiyagari
authors.forename: Albert P
authors.initials: AP
authors.lastname: Rocchini
authors.forename: Robert T
authors.initials: RT
authors.lastname: Remenapp
authors.forename: Joseph N
authors.initials: JN
authors.lastname: Graziano
mesh_terms: D000293:Adolescent; D000328:Adult; D006328:Cardiac Catheterization / Q000295:instrumentation / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D004322:Drainage; D004452:Echocardiography; D015199:Extracorporeal Membrane Oxygenation; D005260:Female; D006325:Heart Atria; D006333:Heart Failure / Q000628:therapy*; D006346:Heart Septum; D006801:Humans; D007223:Infant; D008297:Male; D011654:Pulmonary Edema / Q000517:prevention & control*; D012189:Retrospective Studies; D018487:Ventricular Dysfunction, Left / Q000517:prevention & control*