Extracorporeal life support (ECLS) is an expanding technology for patients in cardiogenic shock. Most patients requiring ECLS can be managed with percutaneous veno-arterial (VA) femoral cannulation. Despite sufficient extracorporeal circulatory support, an unclear number of patients develop left ventricular distension which can result in increased wall tension and stress as well as worsening pulmonary edema. Indications to vent the left ventricle can be controversial. When venting is indicated a number of additional procedures may be considered including inotropic support, intra-aortic balloon pump, Impella, balloon atrial septostomy, or placement of a transseptal cannula. We present a unique case of a femoral VA Extracorporeal membrane oxygenation (ECMO) as bridge to transplant (BTT) with left-sided venting using a Bio-medicus NextGen cannula (Medtronic) with a transseptal approach.
A patient with heart failure due to dilated ischemic cardiomyopathy presented in cardiogenic shock for institution of veno-arterial extracorporeal membrane oxygenation as a bridge to cardiac transplantation. To provide adequate venous drainage and simultaneous decompression of the left atrium (indirect left ventricular venting) a single venous cannula was placed across the interatrial septum so the distal orifice and side ports were located within the left atrium and the proximal set of side ports at the cavoatrial junction. Three-dimensional transesophageal echocardiography demonstrated utility in guiding cannula placement and appropriate positioning within the left atrium.