Percutaneous decompression of the left atrium to treat refractory pulmonary edema in patients supported by extracorporeal membrane oxygenation

Background Previous experience in infants has shown that percutaneous insertion of a cannula into the left atrium incorporated into the extracorporeal membrane oxygenation (ECMO) circuit decreases left cardiac pressures and improves pulmonary edema (PE). However, data on adults is scarce. Purpose This study aimed to evaluate the feasibility and safety of percutaneous decompression of the left atrium (PDLA) in patients supported by ECMO with refractory PE. Methods A total of 23 consecutive patients were included between January 2015 and September 2018. A venous cannula incorporated to the ECMO circuit was inserted into the left atrium via transvenous transseptal catheterization. Data were retrospectively collected. Patients were classified as responders if the blood partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio increased at least by 20% or their respiratory failure improved to a less severe stage, or they were extubated during the first 48 hours. A successful procedure was defined as an adequate placement of the cannula in a patient who left the catheterization room alive. Results PDLA was successfully performed in all patients. One patient (4.3%) had a cardiac tamponade and one (4.3%) a hemothorax. No other procedural complications occurred. At day 2, PaO2/FiO2 ratio increased by 79 ± 143 (P = 0.161). Twelve patients (52.2%) were weaned from ECMO, 13 patients (56.5%) underwent heart transplantation and 10 patients (43.7%) were discharged alive from hospital. At a mean follow-up of 251 ± 288 days, 9 (39.1%) were alive. A total of 11 patients were classified as responders: they were more likely to be weaned from ECMO (54.5% vs. 44.4%, P = 0,391) and mechanical ventilatory support (54.5% vs. 22.2%, P = 0,142) and had a tendency to greater in-hospital survival (54.5% vs. 33.3%, P = 0,343). Conclusions PDLA was feasible, safe and allowed an improvement in oxygenation-status of patients with refractory PE during ECMO support.