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Peer-reviewedCC BY 4.0JACC: Advances

Atrial Septostomy and Left Ventricular Venting During Peripheral VA-ECMO

  • Arjun B Kapoor1
  • Joy Stouffer2
  • Dhruv Sarma1
  • Nanda Nayak1
  • Parth Visrodia1
  • Brandon Petree3
  • Enock Adjei4
  • Amir Teimouri Dereshgi4
  • Emily N Hollis2
  • Jared O'Leary1
  • Bret Alvis5
  • Aaron Williams4
2 more authors
  • Matthew Bacchetta6
  • Aniket S Rali7
7 affiliations
  1. 1Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
  2. 2Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
  3. 3Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
  4. 4Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
  5. 5Department of Anesthesia, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
  6. 6Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, Tennessee, USA.
  7. 7Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA. Electronic address: [email protected].
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Abstract

Background: Peripheral venoarterial (VA)–extracorporeal membrane oxygenation (ECMO) increases left ventricular (LV) afterload, and therefore the risk of LV distension, pulmonary edema, and cardiac stasis. Balloon atrial septostomy (BAS) provides atrial-level unloading, but the durability of LV venting remains uncertain.

Objectives: This study aimed to evaluate the clinical effectiveness of BAS for LV venting in patients requiring peripheral VA-ECMO for cardiogenic shock (CS).

Methods: The authors conducted a retrospective study of consecutive adults with CS supported with peripheral VA-ECMO who underwent BAS for LV unloading at an academic center (2019-2024). The primary endpoint was LV venting failure, a composite of pulmonary edema, LV distension, spontaneous echocardiographic contrast, LV or aortic root thrombus, stroke due to ECMO, or escalation to additional mechanical support.

Results: A total of 28 patients were included in the study. BAS resulted in a significant reduction in mean left atrial pressure (20.5-13.5 mm Hg; P < 0.001). Durable LV venting was achieved in a subset of patients; however, LV venting failure occurred in 53.6%, driven primarily by pulmonary edema. Pulse-pressure trajectories differed according to eventual LV venting-failure status (interaction P = 0.018). Model-estimated pulse pressure was higher at 48 hours (P = 0.010) and 72 hours (P = 0.031) among patients who ultimately did not experience venting failure.

Conclusions: Among patients receiving peripheral VA-ECMO for CS, BAS achieves atrial-level decompression and may provide durable LV venting in select patients, although venting failure remains common. Observed arterial pulse-pressure trajectories differed according to eventual LV venting failure status.

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Cite

BibTeXRIS
BibTeX
@article{kapoor2026atrial,
  title = {{Atrial Septostomy and Left Ventricular Venting During Peripheral VA-ECMO}},
  author = {Arjun B Kapoor and Joy Stouffer and Dhruv Sarma and Nanda Nayak and Parth Visrodia and Brandon Petree and Enock Adjei and Amir Teimouri Dereshgi and Emily N Hollis and Jared O'Leary and Bret Alvis and Aaron Williams and Matthew Bacchetta and Aniket S Rali},
  journal = {JACC: Advances},
  year = {2026},
  month = oct,
  doi = {10.1016/j.jacadv.2026.103344},
  url = {https://doi.org/10.1016/j.jacadv.2026.103344},
  note = {CC BY 4.0},
}
RIS
TY  - JOUR
TI  - Atrial Septostomy and Left Ventricular Venting During Peripheral VA-ECMO
AU  - Arjun B Kapoor
AU  - Joy Stouffer
AU  - Dhruv Sarma
AU  - Nanda Nayak
AU  - Parth Visrodia
AU  - Brandon Petree
AU  - Enock Adjei
AU  - Amir Teimouri Dereshgi
AU  - Emily N Hollis
AU  - Jared O'Leary
AU  - Bret Alvis
AU  - Aaron Williams
AU  - Matthew Bacchetta
AU  - Aniket S Rali
PY  - 2026
DA  - 2026/10/16
JO  - JACC: Advances
DO  - 10.1016/j.jacadv.2026.103344
UR  - https://doi.org/10.1016/j.jacadv.2026.103344
AB  - Background: Peripheral venoarterial (VA)–extracorporeal membrane oxygenation (ECMO) increases left ventricular (LV) afterload, and therefore the risk of LV distension, pulmonary edema, and cardiac stasis. Balloon atrial septostomy (BAS) provides atrial-level unloading, but the durability of LV venting remains uncertain.  Objectives: This study aimed to evaluate the clinical effectiveness of BAS for LV venting in patients requiring peripheral VA-ECMO for cardiogenic shock (CS).  Methods: The authors conducted a retrospective study of consecutive adults with CS supported with peripheral VA-ECMO who underwent BAS for LV unloading at an academic center (2019-2024). The primary endpoint was LV venting failure, a composite of pulmonary edema, LV distension, spontaneous echocardiographic contrast, LV or aortic root thrombus, stroke due to ECMO, or escalation to additional mechanical support.  Results: A total of 28 patients were included in the study. BAS resulted in a significant reduction in mean left atrial pressure (20.5-13.5 mm Hg; P < 0.001). Durable LV venting was achieved in a subset of patients; however, LV venting failure occurred in 53.6%, driven primarily by pulmonary edema. Pulse-pressure trajectories differed according to eventual LV venting-failure status (interaction P = 0.018). Model-estimated pulse pressure was higher at 48 hours (P = 0.010) and 72 hours (P = 0.031) among patients who ultimately did not experience venting failure.  Conclusions: Among patients receiving peripheral VA-ECMO for CS, BAS achieves atrial-level decompression and may provide durable LV venting in select patients, although venting failure remains common. Observed arterial pulse-pressure trajectories differed according to eventual LV venting failure status.
SN  - 2772-963X
ER  -