Percutaneous left atrial unloading to prevent pulmonary oedema and to facilitate ventricular recovery under extracorporeal membrane oxygenation therapy

OBJECTIVES: Left-sided unloading during extracorporeal membrane oxygenation (ECMO) therapy is crucial to prevent pulmonary oedema and facilitate ventricular recovery. We present the case of a 55-year-old man under ECMO therapy with pre-existing left ventricular (LV) thrombus formation and in need of ventricular unloading.

METHODS: We implanted a 21-Fr TandemHeart Protek Solo trans-septal cannula into the left atrium using a trans-septal approach via the femoral vein. The cannula was connected to the venous line of the ECMO circuit. A flow probe and a clamp to reduce flow, if necessary, were attached to the left atrium line. Left atrium flow was adjusted to 900 ml/min under transoesophageal echocardiography control to keep the atrial septum in the mid-line and to prevent suction of the inflow cannula.

RESULTS: After 9 days, the patient was weaned step-wise from ECMO and the TandemHeart cannula, which was then explanted. The patient is in New York health Association Class II without neurological sequelae (Cerebral Performance Scale 1). After 3 months, the patient has fully recovered and is working daily. The LV function is still moderately impaired, and the size of the LV thrombus remains the same. The atrial septum shows no residual defect.

CONCLUSIONS: Percutaneous trans-septal insertion of a TandemHeart cannula incorporated in an ECMO circuit for the prevention of pulmonary oedema and subsequent weaning from extracorporeal circulation was feasible and safe in a patient with cardiogenic shock and an LV thrombus.