Author’s Reply

To the Editor,

We thank Dr. Gökalp et al. (1) entitled “Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest in children after cardiac surgery.” published in Anatol J Cardiol 2017; 17: 328-33. We agree with their comment that increasing afterload caused by veno-arterial (V-A) ECMO may impact left ventricular (LV) function. Increased LV afterload, together with severe systolic dysfunction, may result in LV overload with subsequent increase in left atrial pressure and severe pulmonary edema (2). This is especially true for patients with biventricular physiology, intact atrial septum, and severe left ventricular dysfunction, such as that in dilated cardiomyopathy. Although the experiences of left atrial decompression during V-A ECMO in children are limited, Hacking et al. (3) have suggested that the elective decompression of the left ventricle reduces ECMO duration and increases survival. However, in their study, almost all patients had biventricular physiology, only half of whom had congenital heart disease. As our study included a small number of patients with biventricular physiology, no patient required left atrial decompression. However, after submitting our study, we experienced two patients requiring left atrial decompression. One of them was a 15-year-old boy with dilated cardiomyopathy, and the other was a 3-year-old boy with ventricular septal defect closure and subaortic resection. Both patients received ECPR, and the indication for left atrial decompression was unresolved pulmonary edema. Left atrial decompression was achieved with a second venous cannula inserted through the left atrial appendage, which was connected to the venous line with a “Y” adapter. Atrial septostomy and left ventricular cannulation are other alternatives for left heart decompression during ECMO support (2, 3).

We again thank Dr. Gökalp et al. (1) for giving us the opportunity to emphasize the importance of left heart decompression during V-A ECMO support.