Atrial Septostomy as a Bridge to Replace a Thrombosed Mechanical Aortic Valve Requiring Extracorporeal Membrane...

Atrial septostomy is an infrequently used percutaneous technique to decompress either side of the heart. Here, a case is reported of atrial septostomy performed as an emergency 'bridge' procedure in a hemodynamically unstable 62-year-old man with acute mechanical prosthetic aortic valve thrombosis requiring peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO). ECMO was placed emergently as the patient suffered cardiac arrest during anesthesia induction for surgical replacement of the thrombosed prosthetic aortic valve. The increased afterload as a result of ECMO, in the setting of severe prosthetic valve dysfunction, led to a marked elevation of the left heart pressures, pulmonary edema and multiorgan dysfunction. A percutaneous atrial septostomy led to a rapid decompression of the left heart by shunting blood to the right atrium, allowing for a marked improvement in the patient's clinical condition. This facilitated the performance of re-do surgery to replace the dysfunctional thrombosed aortic prosthetic valve. Postoperatively, the pulmonary edema resolved completely and the patient achieved full recovery with no residual cardiac symptoms at three months. Video: Gated cardiac CT angiography demonstrating a large thrombus present between the St. Jude Medical mechanical aortic prosthetic leaflets, resulting in severe restriction of leaflet motion.