Learning from a pitfall: Atrial septostomy in LV failure under VA-ECMO for pulmonary hypertension

Atrial septostomy has been successfully used in patients with pulmonary hypertension and in those supported with veno-arterial extracorporeal membrane oxygenation (VA-ECMO) complicated by pulmonary congestion.

We report a patient on VA-ECMO for decompensated pulmonary hypertension who subsequently developed stress-induced cardiomyopathy and pulmonary congestion. An atrial septostomy was performed, which led to worsening respiratory status due to the creation of a right-to-left shunt, and hemodynamic deterioration resulting from increased left ventricular preload.

The implications of atrial septostomy should be carefully considered prior to decompression, as there may be situations, especially if right-sided pressures are less than left-sided pressures, where patients may still benefit.