title: Percutaneous balloon atrial septostomy on top of venoarterial extracorporeal membrane oxygenation results in safe and effective left heart decompression.
abstract: BACKGROUND
  Transcatheter techniques are emerging for left atrial (LA) decompression under venoarterial extracorporeal membrane oxygenation (VA-ECMO). We aimed to assess whether balloon atrioseptostomy (BAS) is a safe and efficient strategy.
  
  
  METHODS
  All patients who underwent percutaneous static BAS under VA-ECMO at four tertiary institutions were retrospectively reviewed.
  
  
  RESULTS
  From 2000 to 2014, BAS was performed in 64 patients (32 adults and 32 children). Indications for ECMO support included acute myocarditis (31.3%) and non-myocarditis cardiac disease, mostly end-stage dilated cardiomyopathy (32.8%). BAS was required because of pulmonary oedema/haemorrhage and left ventricular (LV) distension. The mean balloon diameter was 21.8 ± 8.4mm. Adequate LA decompression was achieved in all patients. Mean LA pressure fell from 24.2 ± 6.9 mmHg to 7.8 ± 2.6 mmHg ( p < 0.001). The left-to-right atrial pressure gradient fell from 17.2 ± 7.1 mmHg to 0.09 ± 0.5 mmHg ( p < 0.001). Echocardiography showed an unrestrictive left-to-right atrial shunting in all patients. Improvement of day 1 chest X-ray was observed in 76.6% of patients, clinical status in 98.4% of patients and pulmonary haemorrhage in 14 out of 14 patients. Complications occurred in 9.4% of patients, representing pericardial effusion, fast atrial fibrillation, ventricular fibrillation requiring defibrillation, transient complete heart block and femoral venous dissection requiring covered stent placement. In the 37 (57.8%) patients who were successfully decannulated, the median ECMO duration was 9 (range: 4-24) days. After a median follow-up of 12.3 (range: 0.1-142) months, 35.9% patients died, 17.2% received a LV assist device as a bridge to transplantation, 31.2% were transplanted and 56.2% were home discharged and alive.
  
  
  CONCLUSIONS
  Percutaneous BAS may be a safe and efficient strategy for discharging the LA in both adults and children supported by VA-ECMO.
authors.affiliation: 1 Department of Paediatric Cardiology, Royal Brompton Hospital and Harefield NHS Foundation Trust, Imperial College London, London, UK.|2 Cardiology Clinical Academic Group, Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK.|3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France.
authors.forename: Alban-Elouen
authors.initials: AE
authors.lastname: Baruteau
authors.affiliation: 4 Department of Rheumatology, University Hospital Pellegrin, Bordeaux, France.
authors.forename: Thomas
authors.initials: T
authors.lastname: Barnetche
authors.affiliation: 5 Department of Pediatric Intensive Care, Paris South University Hospitals, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France.
authors.forename: Luc
authors.initials: L
authors.lastname: Morin
authors.affiliation: 3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France.|6 Department of Pediatric Cardiology, Haut-Lévèque Hospital, Bordeaux University, Bordeaux, France.
authors.forename: Zakaria
authors.initials: Z
authors.lastname: Jalal
authors.affiliation: 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
authors.forename: Nicholas S
authors.initials: NS
authors.lastname: Boscamp
authors.affiliation: 8 Department of Pediatric Cardiac Surgery, Marie-Lannelongue Hospital, Paris, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Le Bret
authors.affiliation: 3 IHU LIRYC, Electrophysiology and Heart Modeling Institute, INSERM U1045, Bordeaux, France.|6 Department of Pediatric Cardiology, Haut-Lévèque Hospital, Bordeaux University, Bordeaux, France.
authors.forename: Jean-Benoit
authors.initials: JB
authors.lastname: Thambo
authors.affiliation: 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Vincent
authors.affiliation: 1 Department of Paediatric Cardiology, Royal Brompton Hospital and Harefield NHS Foundation Trust, Imperial College London, London, UK.
authors.forename: Alain
authors.initials: A
authors.lastname: Fraisse
authors.affiliation: 7 Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
authors.forename: Alejandro J
authors.initials: AJ
authors.lastname: Torres
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D006328:Cardiac Catheterization / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D019299:Decompression, Surgical / Q000379:methods*; D004452:Echocardiography; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006325:Heart Atria / Q000000981:diagnostic imaging / Q000601:surgery*; D006331:Heart Diseases / Q000175:diagnosis / Q000601:surgery*; D006346:Heart Septum / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: ECMO support; cardiogenic shock; haemodynamics; outcomes; pulmonary oedema; transcatheter techniques