Transesophageal Echocardiography–Guided Left Heart Decompression via Atrial Septostomy during Venoarterial ECMO: A Report of Four Cases

Venoarterial extracorporeal membrane oxygenation (V-A ECMO) in cardiogenic shock may exacerbate left ventricular distention, necessitating effective decompression strategies. While multiple approaches exist, transesophageal echocardiography-guided transseptal decompression offers potential advantages as a bedside procedure. This study reported four consecutive patients (two pediatric, two adult) receiving V-A ECMO with echocardiography-guided left ventricular decompression via atrial septostomy at one Chinese tertiary referral center (September 2024-January 2025). All procedures successfully achieved catheter placement (10Fr pediatric/12Fr adult) with drainage flows maintaining 120 to 156 mL/min (8% to 10% of ECMO flow). All cases showed reduced left ventricular end-diastolic diameters (mean reduction: pediatric 28 to 26.5 mm, adult 48 to 44.5 mm) and improved systolic function after intervention. Successful ECMO weaning was achieved in all patients, with three surviving to discharge and one death from an unrelated cerebral hemorrhage. No decompression procedure-related complications occurred. This study demonstrates the technical feasibility of transesophageal echocardiography-guided left heart decompression for managing left ventricular overload during V-A ECMO. While the approach appears promising, larger studies are needed to validate its efficacy and safety compared to established methods.