Atrial Septal Defect Creation and Stenting for Left Ventricular Unloading in ECMO-Supported Patients with Potential Reversible Cardiogenic Shock

Background: Venoarterial (VA) ECMO for left ventricular (LV) failure offers the advantage of maintaining tissue perfusion and preventing end-organ failure. ECMO-related increase in aortic root pressure and therewith LV afterload can lead to an elevation in end-diastolic pressure and decrease in LV stroke volume. Reduced myocardial perfusion, arrhythmias, pulmonary venous hypertension and pulmonary edema are further consequences. To counteract this progression, decompression of the left atrium through the creation of an atrial septal defect may become necessary.

Methods: We present a case of a 1-year-old boy with severe myocarditis attributed to Parvovirus B19 (PVB19) infection, who was admitted to our hospital in cardiogenic shock with pronounced LV dilation and pulmonary edema. We share insights into our approach to LV unloading on VA-ECMO for cardiac failure.

Results: Following the establishment of VA-ECMO via the right-sided neck vessels the LA pressure as well as LV end-diastolic pressure were elevated (30mmHg), the LV was markedly dilated. We proceeded to create an ASD using a cutting balloon. Subsequently, a stent placement was deemed necessary to address the remaining restriction. It was only after successfully implementing a stent-in-stent placement that unrestricted left-to-right shunting with sufficient LV decompression was achieved. Pulmonary edema regressed. The boy was subsequently weaned off ECMO after a 22-day period and is currently thriving despite dealing with chronic viral myocarditis as confirmed by endomyocardial biopsy. The stents have not been removed, providing an alternate pathway for left atrial (LA) emptying and preventing high LA and LV filling pressures. In subsequent evaluation, ejection fraction was calculated 43–51% by echocardiography, with invasive hemodynamics revealing cardiac indices of 2.2 L/m²/min and LA pressures of 6–7 mmHg.

Conclusion: A catheter-based approach, involving the creation of an ASD and subsequent stent placement, proved instrumental in achieving effective LV decompression and mitigating the detrimental effects of increased LV afterload. This intervention allowed us to eventually wean patients off ECMO, demonstrating the potential for recovery after severe cardiogenic shock with drastic LV distention.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
13 February 2024