Table 2.
Active left atrial venting
| Venting mode | Authors | Year | Trial Type | Trial demograhics | VA-ECMO-Indication | Venting Technique | Timing of venting initiation | |
|---|---|---|---|---|---|---|---|---|
| Active, left atrium (percutaneous) | Trans-septal cannulation | Kim et al. [25] | 2021 | Singlecenter, retrospective (Enrollment period 2012–2018) | n = 124, median age: 51.7 years (venting group), 61.0 years (control group) (p = 0.001), 78.2% male, rate of decompression in total study population: 50% | AMI: 37.1% (venting), 54.8% (control); acute decompensated heart failure: 48.4% (venting), 14.5% (control); myocarditis: 11.3% (venting), 3.2% (control); valvular heart disease: 1.6% (venting), 11.3% (control); other: 1.6% (venting), 16.1% (control) (p < 0.001); pre-VA-ECMO cardiac arrest: 37.1% (venting), 69.4% (control) (p < 0.001) | Percutaneous insertion of a 20-24Fr cannula into LA | Median interval from VA-ECMO initiation to decompression: 37.5 h |
| Orozco-Hernandez et al. [22] | 2020 | Case report | n = 1, 53 yo, male | PCS | Percutaneous insertion of a 23Fr Bio-Medicus NextGen multistage venous cannula (Medtronic) into LA without additional RA venous cannula | Simultaneous with VA-ECMO initiation | ||
| Kim et al. [28] | 2019 | Singlecenter, retrospective (Enrollment period 2017–2018) | n = 7, median age: 58 years, 57% male | AMI: 42.8%; myocarditis: 42.8%; dilated cardiomyopathy: 14.3%; eCPR before VA-ECMO initiation: 57% | Percutaneous insertion of a 8Fr Mullins sheath into LA | Simultaneous with VA-ECMO initiation: 57%; interval from VA-ECMO initiation to decompression in remaining n = 3 patients: 15 h/30 h/40 h, respectively | ||
| Alhussein et al. [29] | 2017 | Singlecenter, retrospective (Enrollment period 2010–2016) | n = 7, mean age: 33 years, 57% male | AMI: 28%; myocarditis: 28%; non-ischemic cardiomyopathy: 28%; sepsis: 14% | Percutaneous insertion of a 21Fr Bio-Medicus venous cannula (Medtronic) into LA; average duration of procedure: 68 min | Mean interval from VA-ECMO initiation to decompression: 1.3 days | ||
| Lee et al. [34] | 2017 | Case report | n = 1, 72 yo, male | AMI | Percutaneous insertion of a 19Fr cannula (Medtronic) into LA | 2 days after VA-ECMO initiation | ||
| Jumean et al. [24] | 2015 | Case report | n = 1, 30 yo, male | Refractory VF | Percutaneous insertion of a 21Fr Tandem-Heart cannula (CardiacAssist) into LA | Shortly after VA-ECMO initiation | ||
| Swartz et al. [33] | 2012 | Case report | n = 1, 13 yo, female | Acute decompensated heart failure | Percutaneous insertion of a 19Fr cannula (Medtronic) into LA | 6 days after VA-ECMO initiation | ||
| Aiyagari et al. [30] | 2006 | Singlecenter, retrospective (Enrollment period 2003–2005) | n = 7, mean age: 14 years, 43% male | Myocarditis: 28%; non-ischemic cardiomyopathy: 28%; PCS: 14%; cardiac arrest after aspiration: 14%; acute transplant rejection: 14% | Percutaneous insertion of a 10Fr Amplatzer atrial septal occluder delivery sheath, 10-11Fr blue Mullins sheath or 15Fr ECMO cannula into LA; median duration of procedure: 51 min | Median interval from VA-ECMO initiation to decompression: 11 h | ||
| Hlavacek et al. [32] | 2005 | Case report | n = 1, 9 yo, male | Myocarditis | Percutaneous insertion of a 17Fr cannula into LA | 4 days after VA-ECMO initiation | ||
| Active, left atrium (surgical) | Surgical cannulation | No studies available | ||||||
| Active, left atrium (mixed analysis) | Mixed active and passive | Zampi et al. [36] | 2019 | Multicenter, retrospective (Enrollment period 2004–2016) | n = 137, median age: 4.7 years, 49.6% male, rate of decompression in total study population: 100% | Cardiomyopathy: 47%; myocarditis: 16.8%; cardiorespiratory failure of non-cardiac etiology: 10.9%; post-transplantation rejection: 10.2%; repaired congenital heart disease: 6.6%; other: 8.5% | Percutaneous left atrial drain placement: 18%; static balloon atrial septoplasty: 56%; atrial septal stent placement: 10.2%; dynamic balloon atrial septostomy: 6.6%; blade atrial septostomy: 3.6%; surgical/hybrid septostomy: 3.6% | Median interval from VA-ECMO initiation to decompression: 6.2 h |
| Alghanem et al. [26] | 2019 | Singlecenter, retrospective (Enrollment period 2004–2016) | n = 194, rate of decompression in total study population: 11%, 1:1 matched analysis of n = 21 undergoing decompression compared to n = 21 VA-ECMO alone | Cardiorespiratory failure of non-cardiac etiology: 36%; congenital diaphragmatic hernia: 34%; pulmonary hypertension: 7%; cardiomyopathy /myocarditis: 7%; repaired congenital heart disease: 6%; meconium aspiration syndrome: 3% [unmatched cohort] | Percutaneous LA cannulation and drainage (n = 12), balloon septoplasty (n = 8) and septal stent implantation (n = 1) | Average interval from VA-ECMO initiation to decompression: 7 h | ||
| Mixed percutaneous and surgical techniques | Na et al. [23] | 2019 | Singlecenter, retrospective (Enrollment period 2013–2016) | n = 50 patients, median age: 49 years (therapeutic decompression group, n = 32), 47 years (prophylactic decompression group, n = 18), 53.1% (therapeutic), 72.2% (prophylactic) male | AMI: 31.3% (therapeutic), 0% (prophylactic); acute decompensated heart failure: 40.6% (therapeutic), 88.9% (prophylactic); valvular heart disease: 6.3% (therapeutic), 0% (prophylactic); myocarditis: 18.8% (therapeutic), 11.1% (prophylactic); stress-induced cardiomyopathy: 3.1% (therapeutic), 0% (prophylactic) | Percutaneous insertion of a 21-25Fr cannula into LA; rate of percutaneous decompression: 43.8% (therapeutic), 100% (prophylactic); 53.1% of patients undergoing LA decompression did not require a seperate venous RA draining cannula | Median interval from VA-ECMO initiation to decompression: 38.8 h (therapeutic) | |
| Mixed percutaneous techniques | Eastaugh et al. [31] | 2015 | Singlecenter, retrospective (Enrollment period 2000–2011) | n = 44, median age: 9.7 years (myocarditis group), 10.8 years (non-myocarditis group), 55% male | Myocarditis: 50%; non-Myocarditis: 50% | Percutaneous LA cannulation and drainage: 57% (15/19Fr BioMedicus cannula (Medtronic), 9Fr Mullins sheath (Cook), 4Fr Radiofocus Glidecath (Terumo medical), 8.3Fr pigtail catheter (Cook)); static balloon septoplasty: 39%; septal stent implantation: 4% | Median interval from VA-ECMO initiation to decompression: 11.5 h (myocarditis), 16 h (non-myocarditis) (p = 0.24); median interval from VA-ECMO initiation to decompression: 21 h (before 2003), 9 h (after 2003) | |
| Blade septostomy vs. Mixed surgical venting techniques (left atrium, left ventricle) | Hacking et al. [37] | 2015 | Singlecenter, retrospective (Enrollment period 1990–2013) | n = 49, mean age: 3.6 months (elective decompression group), 5.2 months (emergency decompression group), 66% (elective), 45% (emergency) male | Congenital heart disease requiring cardiac surgery: 62% (elective), 31% (emergency) (p = 0.05); other: 38% (elective), 68% (emergency) | Surgical left atrial insertion of venting cannula into interatrial groove: 86% (elective), 64% (emergency) (p = 0.1); surgical trans-apical left ventricular decompression: 14% (elective), 23% (emergency) (p = 0.47); percutaneous blade septostomy: 7% (elective), 14% (emergency) (p = 0.64); proportion of patients on central VA-ECMO: 93% (elective), 68% (emergency) (p = 0.02) | Simultaneous with VA-ECMO initiation: 56% (elective); median interval from VA-ECMO initiation to decompression: 31.4 h (emergency) | |
| Mixed surgical vs. Percutaneous | Ok et al. [27] | 2019 | Singlecenter, retrospective (Enrollment period 2012–2016) | n = 70, median age: 57.4 years (no decompression group), 43.8 years (decompression group) (p = 0.001), 55.6% (no decompression), 56% (decompression) male, matched analysis of n = 25 with pulmonary edema and arterial pulse pressure < 10 mmHg undergoing decompression compared with n = 45 VA-ECMO alone | AMI: 35.6% (no decompression), 16.0% (decompression); acute decompensated heart failure: 11.1% (no decompression), 44.0% (decompression); PCS: 28.9% (no decompression), 12.0% (decompression); other: 24.4% (no decompression), 28.0% (decompression) | Percutaneous insertion of a 20-28Fr cannula into LA; surgical trans-apical LV venting catheter insertion simultaneous with central VA-ECMO initiation in n = 5; flow rate range of venting cannula: 1.859–3.940 ml/min | Mean interval from VA-ECMO initiation to decompression: 3 days | |
| Mixed surgical vs. Percutaneous | Kotani et al. [21] | 2013 | Singlecenter, retrospective (Enrollment period 2005–2011) | n = 178, rate of decompression in total study population: 12.9% (median age: 1.8 months, 60% male) | PCS: 82.6% | Surgical insertion of cannula into LA: 68.8% (decannulation group), 71.4% (unsuccessful decannulation group); percutaneous balloon atrial septostomy: 18.8% (decannulation), 14.3% (unsuccessful decannulation); surgical adjustable atrial septostomy: 12.5% (decannulation), 14.3% (unsuccessful decannulation) | Median interval from VA-ECMO initiation to decompression: 3.0 h (decannulation), 1.71 h (unsuccessful decannulation); simultaneous decompression with VA-ECMO initiation: 70% | |
| Venting mode | Mechanical support duration | Follow-up time | Hemodynamic effect of decompression | Mortality outcome | Additional outcome information | Complications/adverse events | |
|---|---|---|---|---|---|---|---|
| Active, left atrium (percutaneous) | Trans-septal cannulation | Median duration of VA-ECMO: 237 h (venting), 71 h (control) (p < 0.001) | No infor-mation | Radiographical assessment of pulmonary edema: improvement: 61.3%; no improvement: 33.9%; worsened: 4.8% (p = 0.003) | In-hospital mortality rate: 56.5% (venting), 69.4% (control) (p = 0.191) | Weaning rate: 61.3% (venting), 38.7% (control) (p = 0.012); serum lactate 24 h after decompression associated with VA-ECMO weaning: OR 0.58 (p = 0.012) | Bleeding: 4.8% (venting), 6.5% (control); limb ischemia: 0% (venting), 4.8% (control); cardiac tamponade: 3.2% (venting), 0% (control); thrombosis: 4.8% (venting), 0% (control); complications related to venting procedure: left femoral puncture site hematoma (n = 1), cardiac tamponade requiring operative exploration (n = 1) |
| Duration of VA-ECMO: 3 days | No infor-mation | No information | Patient survived | Patient underwent heart transplantation 3 days after VA-ECMO initiation | No procedure-related complications reported | ||
| Median duration of VA-ECMO: 185 h | No infor-mation | Improvement of pulmonary edema within 3 days: 57% | In-hospital mortality rate: 14% | Weaning rate: 85.7%; bridge to heart transplantation: 14% | Venting catheter obstruction: 14% | ||
| Median duration of VA-ECMO: 5 days | No infor-mation | Decrease in LA size, LA pressure, LVEDD and PA pressure post decompression (data availability limited); improvement of radiographical signs of pulmonary congestion post decompression in all patients | In-hospital mortality rate: 28% | Bridge to heart transplantation: 28%; bridge to LVAD: 28%; cardiac recovery: 14% | No procedure-related complications reported; closure of atrial septal defect at the time of VA-ECMO removal in two survivors who underwent LVAD implantation | ||
| Duration of VA-ECMO: 7 days | Hospita-lization | Reduced pulmonary edema and cardiomegaly | Patient survived | No information | No procedure-related complications reported | ||
| Duration of VA-ECMO: 2 days | 21 days | Reduced biventricular filling pressures | Patient died 14 days after LVAD implantation | Patient underwent LVAD implantation 2 days after VAVA-ECMO initiation | No procedure-related complications reported | ||
| Duration of VA-ECMO: 11 days | Hospita-lization | VA-ECMO flow: 2.5 L/min (pre decompression), 4.5 L/min (post decompression); echocardiographic imaging showed sufficient LA and LV decompression | Patient survived | No information | Small left-to-right shunt across the atrial septum | ||
| Median duration of VA-ECMO: 172 h | No infor-mation | Echocardiographic improvement of left atrial dilatation: 71% | In-hospital mortality rate: 57% | Average sheath size compared to body surface area: 13Fr/m2 (successful procedures), 6Fr/m2 (unsuccessful procedures) (p < 0.05); maximum LA cannula flow: 497 ml/min/m2 (successful procedures), 265 ml/min/m2 (unsuccessful procedures) (not significant); VA-ECMO decannulation rate: 57% | No procedure-related complications reported | ||
| Duration of VA-ECMO: 42 days | Hospita-lization | LA pressure: 57 mmHg (pre decompression), 18 mmHg (post decompression); normalization of LA size, resolution of pulmonary edema | Patient survived | Patient underwent heart transplantation 42 days after VA-ECMO initiation | No procedure-related complications reported | ||
| Active, left atrium (surgical) | Surgical cannulation | ||||||
| Active, left atrium (mixed analysis) | Mixed active and passive | Median duration of VA-ECMO: 6 days | 3.2 years | No information | 30-day mortality rate: 26%; 1-year mortality rate: 34% | No difference in survival rates between early (< 18 h) and late (> 18 h) decompression; duration of VA-ECMO: 5 days (early decompression), 8.5 days (late decompression) (p = 0.02); ICU lenght of stay: 18.5 days (early decompression), 28 days (late decompression) (p = 0.03) | Bleeding: 2.9%; arrhythmia: 2.2%; cardiac perforation: 1.5%; escalation of inotropic or ECMO support: 1.5%; pericardial effusion: 0.7% |
| No information | No infor-mation | Mean LA pressure: 24 mmHg (pre decompression), 14 mmHg (post decompression) (p = 0.022); trend towards decreased LA volume within 96 h compared to no LA decompression (p = 0.058) | In-hospital mortality rate: 29% (with decompression), 38% (without decompression) (p = 0.513) | Hospitalization length: 60 days (with decompression), 27 days (without decompression) (p = 0.012); ICU length of stay: 52 days (with decompression), 18 days (without decompression) (p = 0.008) | Drain malpositioning: 14.2%; arrhythmias: 9.5%; no major procedure-related complications reported | ||
| Mixed percutaneous and surgical techniques | Median duration of VA-ECMO: 10.5 days (therapeutic), 15.4 days (prophylactic) (p = 0.332) | 90 days | No information | 30-day mortality rate: 34.4% (therapeutic), 5.6% (prophylactic) (p = 0.036); 90-day mortality rate: 43.8% (therapeutic), 22.2% (prophylactic) (p = 0.128); overall mortality rate while on VA-ECMO: 30% | Weaning rate: 62.5% (therapeutic), 83.3% (prophylactic) (p = 0.123); bridge to LVAD/heart transplantation: 66.7% (therapeutic), 37.5% (prophylactic) (p = 0.048) | Insertion site bleeding: 18.8% (therapeutic), 33.3% (prophylactic) (p = 0.309); gastrointestinal bleeding: 9.4% (therapeutic), 11.1% (prophylactic) (p = 0.999); insertion site infection: 9.4% (therapeutic), 16.7% (prophylactic) (p = 0.654); limb ischemia: 12.5% (therapeutic), 5.6% (prophylactic) (p = 0.642); stroke: 9.4% (therapeutic), 11.1% (prophylactic) (p = 0.999); septostomy-related complications: 9.4% (therapeutic), 5.6% (prophylactic) (p = 0.999) | |
| Mixed percutaneous techniques | Duration of VA-ECMO: 226 h (myocarditis), 74 h (non-myocarditis) | No infor-mation | Median LA pressure: 24 mmHg (pre decompression), 17 mmHg (post decompression) (p = 0.002); improvement of chest-Xray-score seen in 73% with available data (median interval from decompression to chest-Xray: 62.8 h) | Mortality rate: 29% | n = 10 patients underwent heart transplantation | Persistent atrial septal defect in surviving patients, who did not undergo heart transplantation: 24% | |
| Blade septostomy vs. Mixed surgical venting techniques (left atrium, left ventricle) | Mean duration of VA-ECMO: 128 h (elective), 236 h (emergency) (p = 0.013); mean duration of decompression: 111 h (elective), 154 h (emergency) (p = 0.13) | No infor-mation | No information | Survival to ICU discharge rate: 38% (elective), 45% (emergency) (p = 0.40) | Duration of VA-ECMO in non-survivors: 133 h (elective), 354 h (emergency) (p = 0.002); bridge to durable LVAD: 24% (elective), 13% (emergency) (p = 0.34) | No information | |
| Mixed surgical vs. Percutaneous | Median duration of VA-ECMO: 7.2 days (no decompression), 9.2 days (decompression) (p < 0.001) | Nno infor-mation | No information | Survival to discharge rate: 22.2% (no decompression), 44% (decompression) (p = 0.11) | Weaning rate: 37.8% (no decompression), 60.0% (decompression) (p = 0.08) | Bleeding: 4.4% (no decompression), 8.0% (decompression); distal malperfusion: 4.4% (no decompression), 12.0% (decompression); overall complication rate: 8.9% (no decompression), 20% (decompression) (p = 0.26) | |
| Mixed surgical vs. Percutaneous | Duration of VA-ECMO: 5.9 days | No infor-mation | Improvement of LV function, when initial severe impairment: 60% (decannulation), 20% (unsuccessful decannulation); resolution of pumlonary edema in n = 12 after LA decompression | In-hospital mortality rate: 48% | Duration of VA-ECMO: 4.6 days (decannulation), 10.2 days (unsuccessful decannulation) | Average complications per patient: 1.06 (decannulation), 2.71 (unsuccessful decannulation) | |
VA-ECMO, venoarterial extracorporeal membrane oxygenation; AMI, acute myocardial infarction; PCS, postcardiotomy shock; eCPR, extracorporeal cardiopulmonary resuscitation; VF, ventricular fibrillation; PA, pulmonary artery; RA, right atrium; LA, left atrium; LV, left ventricle; LVEDD, left ventricular end-diastolic diameter; LVAD, left ventricular assist device; ICU, intensive care unit; OR, odds ratio